Postoperative outcomes for Nunavut Inuit at a Canadian quaternary care centre: a retrospective cohort study.

BACKGROUND: Structural aspects of health care systems, such as limited access to specialized surgical and perioperative care, can negatively affect the outcomes and resource use of patients undergoing elective and emergency surgical procedures. The aim of this study was to compare postoperative outcomes of Nunavut Inuit and non-Inuit patients at a Canadian quaternary care centre. METHODS: We conducted a retrospective cohort study involving adult (age ≥ 18 yr) patients undergoing inpatient surgery from 2011 to 2018 at The Ottawa Hospital, the quaternary referral hospital for the Qikiqtaaluk Region of Nunavut. The study was designed and conducted in collaboration with Nunavut Tunngavik Incorporated. The primary outcome was a composite of in-hospital death or complications.Secondary outcomes included postoperative length of stay in hospital, adverse discharge disposition, readmissions within 30 days and total hospitalization costs. RESULTS: A total of 98 701 episodes of inpatient surgical care occurred among patients aged 18 to 104 years; 928 (0.9%) of these involved Nunavut Inuit, and 97 773 involved non-Inuit patients. Death or postoperative complication occurred more often among Nunavut Inuit than non-Inuit patients (159 [17.2%] v. 15 691 [16.1%]), which was significantly different after adjustment for age, sex, surgical specialty, risk and urgency (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.03-1.51). This association was most pronounced in cases of cancer (OR 1.63, 95% CI 1.03-2.58) and elective surgery (OR 1.58, 95% CI 1.20-2.10). Adjusted rates of readmission, adverse discharge disposition, length of stay and total costs were significantly higher for Nunavut Inuit. INTERPRETATION: Nunavut Inuit had a 25% relative increase in their odds of morbidity and death after surgery at a major quaternary care hospital in Canada compared with non-Inuit patients, while also having higher rates of other adverse outcomes and resource use. An examination of perioperative systems involving patients, Inuit leadership, health care providers and governments is required to address these differences in health outcomes.

Utility of exercise electrocardiography testing for the diagnosis of coronary artery disease in a remote Australian setting.

OBJECTIVE: To determine the utility of exercise electrocardiography testing (EET) in evaluating suspected coronary artery disease in a remote Australian setting where a significant proportion of patients are Indigenous Australians. DESIGN: Retrospective cohort study with grouping based on EET results. PATIENTS AND SETTING: 268 patients with suspected coronary artery disease who underwent EET at Alice Springs Hospital--a specialist teaching hospital in Central Australia with no resident specialist cardiology service--in the period 1 June 2009 to 31 May 2010. MAIN OUTCOME MEASURES: Diagnosis of coronary artery disease, based on coronary angiography and/or admission with acute coronary syndrome, in the 24 months after EET. RESULTS: Indigenous patients were younger, more likely to be women and were twice as likely as non-Indigenous patients to have a chronic disease. Indigenous patients and those with a chronic disease had a higher proportion of inconclusive results. Completed EET had a positive predictive value of 48.1% (95% CI, 28.7%-68.1%) and a negative predictive value of 96.5% (95% CI, 93.2%-98.5%). Similar results were seen among Indigenous and non-Indigenous patients. CONCLUSIONS: In regional and remote Australian settings, EET remains an important tool for the diagnosis of coronary artery disease. It is useful, and is reassuring to patients and clinicians if the result is negative, particularly in a remote Indigenous Australian population with a significant burden of cardiovascular risk.

Risk factors for rhabdomyolysis with simvastatin and atorvastatin.

OBJECTIVE: To assess the frequency of risk factors for rhabdomyolysis with simvastatin and atorvastatin in cases reported to the Australian Adverse Drug Reactions Advisory Committee (ADRAC). DESIGN: Reports meeting the definition of rhabdomyolysis were reviewed for risk factors including age > or = 70 years, dose > or = 40 mg, hepatic dysfunction, diabetes mellitus, hyperkalaemia, hypothyroidism and the use of concomitant interacting medications. RESULTS: Only one report associated with simvastatin and five reports associated with atorvastatin did not list any risk factors for rhabdomyolysis. Interacting medicines featured in 77% of reports of rhabdomyolysis associated with simvastatin and 44% of reports associated with atorvastatin. A comparison of the age profile for reports of atorvastatin- and simvastatin-associated rhabdomyolysis with that for all adverse drug reaction reports received, and for all reports of muscle disorders, suggested a trend towards an increasing risk of rhabdomyolysis with increasing age with simvastatin but not with atorvastatin. Similarly, comparing prescribed tablet strengths from Pharmaceutical Benefits Scheme data with the HMG-CoA reductase inhibitor ('statin') doses in reports of rhabdomyolysis suggested a dose-related risk with simvastatin, but a less increased risk with high-dose atorvastatin. CONCLUSION: Risk factors for rhabdomyolysis featured in nearly all of the reports of statin-associated rhabdomyolysis and the majority of reports listed multiple risk factors, although dependence on risk factors appeared to be stronger with simvastatin than atorvastatin. The multiplication of risk factors in patients taking simvastatin and atorvastatin should be minimised.