Basal Insulin Initiation in Adults With Type 2 Diabetes Mellitus: A Retrospective Cohort Study Using Administrative Health Data in Alberta, Canada.

OBJECTIVES: Pharmacologic treatment of type 2 diabetes mellitus (T2DM) follows a stepwise approach. Typically, metformin monotherapy is first-line treatment, followed by other noninsulin antihyperglycemic agents (NIAHAs) or progression to insulin if glycated hemoglobin (A1C) targets are not achieved. We aimed to describe real-world patterns of basal insulin initiation in people with T2DM, and A1C not at target despite treatment with at least 2 NIAHAs. METHODS: A retrospective cohort study was conducted using administrative health data from Alberta, Canada, among adults with T2DM, indexed on the first test with 7.0% < A1C < 9.5% (April 1, 2011 to March 31, 2019), with at least 2 previous NIAHAs but no insulin. Kaplan-Meier (KM) methodology was used to analyze time to basal insulin initiation, with stratification by index A1C. Annual patient status was categorized into 5 groups: basal insulin initiation, death, NIAHA intensification, no change in therapy (subgroups of A1C <7.1% and A1C ≥7.1% [clinical inertia]), or discontinuance. RESULTS: The cohort included 14,083 individuals. The KM cumulative probability of initiating basal insulin was 7.7% (95% confidence interval [CI] 7.3% to 8.2%) at 1 year, increasing to 43.1% (95% CI 42.1% to 44.1%) at 8 years of follow-up. Higher A1C levels were associated with greater proportions of basal insulin initiation. By year 8, proportions with NIAHA intensification and clinical inertia were 12.1% and 19.3%, respectively, relative to year 7. CONCLUSIONS: Despite current clinical practice guidelines recommending achieving A1C targets within 6 months, less than half of the individuals with T2DM and clear indications for basal insulin initiated treatment within 8 years. Efforts to reduce delays in basal insulin initiation are needed.

The contribution of excise cigarette taxes on the decline in youth smoking in Canada during the time of the Federal Tobacco Control Strategy (2002-2012).

OBJECTIVES: To evaluate the impact of changes in cigarette taxes on smoking for youths aged 15-18 in Canada during the time of the Federal Tobacco Control Strategy (FTCS). METHODS: We used a difference-in-differences framework and leveraged the variation in cigarette taxes across Canada and over time. We used regression models with province and year fixed effects, and individual-level and provincial-level covariates on 2002-2012 data from the Canadian Tobacco Use Monitoring Survey. RESULTS: Tax increases generally did not affect smoking outcomes. Each increase of CAD $1.00 (adjusted to year 2000 dollars) in excise cigarette taxes per package of 20 was associated with a 0.2 percentage point (95% CI: -1.8; 2.2) change in smoking prevalence, and a change of 0.3 in mean cigarettes smoked in the past week (95% CI: -1.2; 1.8). CONCLUSION: From 2002 to 2012, smoking prevalence and mean smoking frequency were in steady decline among youths in Canada. This decline, however, was evident even among provinces with stable or decreasing cigarette tax levels. Tobacco taxes have mostly increased since the 1980s, and so, tax levels were already quite high by the launch of the FTCS. Province fixed effects and common temporal changes accounted for 83.7% of the variation in smoking prevalence. We derived similar results for smoking frequency. The cumulative tax increase during our study period was at least $1.00 for only three provinces. Thus, our findings suggest that factors driving down tobacco use among youths in all provinces appear to outweigh any impact of small tax increases at already high tax levels.

How equitable is access to treatment for lung cancer patients? A population-based review of treatment practices in Ontario.

AIM: Guideline concordance is one of the metrics used by the Cancer Quality Council of Ontario and Cancer Care Ontario to assess the quality of cancer care and to drive quality improvement. MATERIALS & METHODS: The rates for lung cancer surgical resection and concordance with the Cancer Care Ontario postoperative adjuvant chemotherapy (AC) guideline were assessed by health region during two time periods (2010-2011 and 2012-2013) according to five equity measures (age, sex, neighborhood income, location of residence and size of immigrant population). RESULTS: Of the patients with stage I/II NSCLC, 52.2% to 63.0% underwent surgical resection in the province of Ontario, Canada; for patients with stage IIIA disease, the rate was 26.4%. The probability of a surgical resection decreased substantially with age; only 26.9% of those with potentially resectable (stage I-IIIA) disease over 80 years underwent surgery. The use of postoperative AC increased modestly over the time of the study but the rate of use varied widely by health region (34.6 to 84.6%). Patients in rural areas were as likely to receive AC as urban dwellers; however, older aged patients (≥65 years) and those from the lowest income neighborhoods were significantly less likely to receive AC. CONCLUSION: Surgical rates and the use of AC vary by health region in Ontario and by age and level of neighborhood income despite universal access in a publicly funded health care system. The reasons for this variance are unclear but warrant further study.Presented in part at the 15th World Conference on Lung Cancer, Sydney, Australia, 27-30 October 2013.