Risk of Bone Fractures Following Urinary Intestinal Diversion: A Population Based Study.

PURPOSE: Patients with bladder cancer who undergo intestinal urinary diversion may be at increased risk for bone fractures thought to be secondary to chronic metabolic acidosis and ensuing bone loss. Our main objective was to assess whether patients who undergo intestinal urinary diversion are at increased risk for fracture. MATERIALS AND METHODS: Patients who underwent intestinal urinary diversion between 1994 and 2014 in Ontario, Canada were identified using linked administrative databases. Patients were categorized as undergoing diversion for bladder cancer or nonbladder cancer causes and matched 4:1 to a healthy cohort. We determined incidence rates of the incidence of fractures per 100 person-years. Multivariable Cox proportional hazards models were used to evaluate the impact of intestinal urinary diversion on the risk of fracture. RESULTS: Overall 4,301 patients with and 907 without bladder cancer underwent intestinal urinary diversion. The fracture incidence rate was significantly greater in the bladder cancer and nonbladder cancer cohorts compared to respective matched controls. In the bladder cancer cohort vs matched controls there were 4.41 vs 2.63 fractures per 100 person-years and in the nonbladder cancer cohort vs matched controls there were 5.67 vs 3.51 fractures per 100 person-years (each p <0.001). On multivariable analysis patients who underwent intestinal urinary diversion for bladder cancer or nonbladder cancer reasons had significantly shorter fracture-free survival compared to the respective matched cohorts (HR 1.48, IQR 1.35-1.63, and HR 1.48, IQR 1.31-1.69, respectively). CONCLUSIONS: Our results demonstrated that regardless of age patients with intestinal urinary diversion are at increased risk for bone fractures compared to the general population. Our findings are in line with previous reports and support the need for bone health monitoring.

Optimal Timing of Physician Visits after Hospital Discharge to Reduce Readmission.

OBJECTIVE: To identify the optimal timing of in-person physician visit after hospital discharge to yield the largest reduction in readmission among elderly or chronically ill patients. DATA SOURCES/STUDY SETTING/EXTRACTION METHODS: We extracted insurance billing data on 620,656 admissions for any cause from 2002 to 2009 in Quebec, Canada. STUDY DESIGN: We used flexible survival models to estimate inverse probability weights for the precise timing (days) of in-person physician visit after discharge and weighted competing risk outcome models. PRINCIPAL FINDINGS: Readmission reduction associated with in-person physician visits (compared to none) was seen early after discharge, with 67.8 fewer readmissions per 1,000 discharges if physician visit occurred within 7 days (95 percent CI: 66.7-69.0), and 110.0 fewer readmissions within 21 days (95 percent CI: 108.2-111.7). The period of largest contribution to readmission reduction was seen in the first 10 days, while physician visits occurring later than 21 days after discharge did not further contribute to reducing hospital readmissions. Larger risk reductions were observed among patients in the highest morbidity level and for in-person follow-up with a primary care physician rather than a medical specialist. CONCLUSIONS: When provided promptly, postdischarge in-person physician visit can prevent many readmissions. The benefits appear optimal when such visit occurs within the first 10 days, or at least within the first 21 days of discharge.

Team-based innovations in primary care delivery in Quebec and timely physician follow-up after hospital discharge: a population-based cohort study.

BACKGROUND: Outpatient follow-up has been a key intervention point in addressing gaps in care after hospital discharge. We sought to estimate the association between enrolment in new team-based primary care practices and 30-day postdischarge physician follow-up among older patients and patients with chronic illnesses who were admitted to hospital in Quebec, Canada. METHODS: Patients were selected into this cohort if a primary care physician enrolled them as a "vulnerable patient" between November 2002 and January 2005. Data for this analysis included province-wide health insurance claims for inpatient and outpatient services delivered between November 2002 and January 2009 in Quebec. The primary analysis examined time to the first outpatient postdischarge follow-up service provided by either a primary care physician or a medical specialist. We used marginal structural models to estimate adjusted rates of follow-up with a primary care physician or with a medical specialist by primary care delivery models. RESULTS: We extracted billing data for 312 377 patients that represented 620 656 index admissions for any cause from 2002 to 2009. Rates of 30-day follow-up were 374 visits to primary care physicians and 422 visits to medical specialists per 1000 discharges. Rates of primary care physician follow-up were similar across primary care delivery models, except for patients with very high morbidity; these patients had significantly higher rates of follow-up with a primary care physician if they were enrolled in team-based primary care practices (30-d rate difference [RD] 13.3 more follow-up visits per 1000 discharges, 95% confidence interval [CI] 6.8 to 19.8). Rates of follow-up with a medical specialist were lower among patients enrolled in team-based practices, particularly within 15 days of hospital discharge (15-d RD 25.1 fewer follow-up visits per 1000 discharges, 95% CI 21.1 to 29.1). INTERPRETATION: Our study found lower rates of postdischarge follow-up with a medical specialist among older patients and patients with chronic illness who were enrolled in team-based primary care practices compared with those enrolled in traditional primary care practices. Future research is needed to better understand the role of primary health care service organization in improving acute postdischarge care.

Team-based versus traditional primary care models and short-term outcomes after hospital discharge.

BACKGROUND: Strategies to reduce hospital readmission have been studied mainly at the local level. We assessed associations between population-wide policies supporting team-based primary care delivery models and short-term outcomes after hospital discharge. METHODS: We extracted claims data on hospital admissions for any cause from 2002 to 2009 in the province of Quebec. We included older or chronically ill patients enrolled in team-based or traditional primary care practices. Outcomes were rates of readmission, emergency department visits and mortality in the 90 days following hospital discharge. We used inverse probability weighting to balance exposure groups on covariates and used marginal structural survival models to estimate rate differences and hazard ratios. RESULTS: We included 620 656 index admissions involving 312 377 patients. Readmission rates at any point in the 90-day post-discharge period were similar between primary care models. Patients enrolled in team-based primary care practices had lower 30-day rates of emergency department visits not associated with readmission (adjusted difference 7.5 per 1000 discharges, 95% confidence interval [CI] 4.2 to 10.8) and lower 30-day mortality (adjusted difference 3.8 deaths per 1000 discharges, 95% CI 1.7 to 5.9). The 30-day difference for mortality differed according to morbidity level (moderate morbidity: 1.0 fewer deaths per 1000 discharges in team-based practices, 95% CI 0.3 more to 2.3 fewer deaths; very high morbidity: 4.2 fewer deaths per 1000 discharges, 95% CI 3.0 to 5.3; p < 0.001). INTERPRETATION: Our study showed that enrolment in the newer team-based primary care practices was associated with lower rates of postdischarge emergency department visits and death. We did not observe differences in readmission rates, which suggests that more targeted or intensive efforts may be needed to affect this outcome.

The impact of primary care reform on health system performance in Canada: a systematic review.

BACKGROUND: We aimed to synthesize the evidence of a causal effect and draw inferences about whether Canadian primary care reforms improved health system performance based on measures of health service utilization, processes of care, and physician productivity. METHODS: We searched the Embase, PubMed and Web of Science databases for records from 2000 to September 2015. We based our risk of bias assessment on the Grading of Recommendations Assessment, Development and Evaluation guidelines. Full-text studies were synthesized and organized according to the three outcome categories: health service utilization, processes of care, and physician costs and productivity. RESULTS: We found moderate quality evidence that team-based models of care led to reductions in emergency department use, but the evidence was mixed for hospital admissions. We also found low quality evidence that team-based models, blended capitation models and pay-for-performance incentives led to small and sometimes non-significant improvements in processes of care. Studies examining new payment models on physician costs and productivity were of high methodological quality and provided a coherent body of evidence assessing enhanced fee-for-service and blended capitation payment models. CONCLUSION: A small number of studies suggested that team-based models contributed to reductions in emergency department use in Quebec and Alberta. Regarding processes of diabetes care, studies found higher rates of testing for blood glucose levels, retinopathy and cholesterol in Alberta's team-based primary care model and in practices eligible for pay-for-performance incentives in Ontario. However pay-for-performance in Ontario was found to have null to moderate effects on other prevention and screening activities. Although blended capitation payment in Ontario contributed to decreases in the number of services delivered and patients seen per day, the number of enrolled patients and number of days worked in a year was similar to that of enhanced fee-for-service practices.

An update to the Greig Health Record: Executive summary.

The Greig Health Record is an evidence-based health promotion guide for clinicians caring for children and adolescents 6 to 17 years of age. It provides a template for periodic health visits that is easy to use and adaptable for electronic medical records. On the record, the strength of recommendations is indicated in boldface for good, in italics for fair, and in regular typeface for recommendations based on consensus or inconclusive evidence. Checklist templates include sections for Weight, Height and BMI, Psychosocial history and Development, Nutrition, Education and Advice, Specific Concerns, Examination, Assessment, Immunization, and Medications. Included with the checklist tables are five pages of selected guidelines and resources. This update includes information from recent guidelines and research in preventive care for children and adolescents 6 to 17 years of age. Regular updates are planned. The complete Greig Health Record can be found online at the Canadian Paediatric Society's website: www.cps.ca.

Le relevé médical Greig est un guide de promotion de la santé fondé sur des données probantes destiné aux cliniciens qui s'occupent d'enfants et d'adolescents de six à 17 ans. Ce modèle pour les bilans de santé périodiques est facile à utiliser et adaptable aux dossiers médicaux électroniques. Sur le relevé, les recommandations sont indiquées en caractères gras lorsqu'elles sont de bonne qualité, en caractères italiques lorsqu'elles sont de qualité acceptable, et en caractères normaux lorsqu'elles sont consensuelles ou peu concluantes. Les listes de vérification comprennent des rubriques sur le poids, la taille et l'indice de masse corporelle, l'histoire psychosociale et le développement, la nutrition, l'éducation et les conseils, les problèmes particuliers, les examens, les évaluations, la vaccination et les médicaments. Elles s'accompagnent de cinq pages de lignes directrices et de ressources sélectionnées. La présente mise à jour contient de l'information tirée des lignes directrices et des recherches récentes sur les soins préventifs pour les enfants et les adolescents de six à 17 ans. Des mises à jour régulières sont prévues. Il est possible de consulter l'intégralité du relevé médical Greig, en anglais, dans le site Web de la Société canadienne de pédiatrie, à l'adresse www.cps.ca.

Rourke Baby Record 2014: Evidence-based tool for the health of infants and children from birth to age 5.

OBJECTIVE: To update the 2011 edition of the Rourke Baby Record (RBR) by reviewing current best evidence on health supervision of infants and children from birth to 5 years of age. QUALITY OF EVIDENCE: The quality of evidence was rated with the former (until 2006) Canadian Task Force on Preventive Health Care classification system and GRADE (grading of recommendations, assessment, development, and evaluation) approach. MAIN MESSAGE: New evidence has been incorporated into the 2014 RBR recommendations related to growth monitoring, nutrition, education and advice, development, physical examination, and immunization. Growth is monitored with the World Health Organization growth charts that were revised in 2014. Infants' introduction to solid foods should be based on infant readiness and include iron-containing food products. Delaying introduction to common food allergens is not currently recommended to prevent food allergies. At 12 months of age, use of an open cup instead of a sippy cup should be promoted. The education and advice section counsels on injuries from unstable furniture and on the use of rear-facing car seats until age 2, and also includes information on healthy sleep habits, prevention of child maltreatment, family healthy active living and sedentary behaviour, and oral health. The education and advice section has also added a new environmental health category to account for the effects of environmental hazards on child health. The RBR uses broad developmental surveillance to recognize children who might be at risk of developmental delays. Verifying tongue mobility and patency of the anus is included in the physical examination during the first well-baby visit. The 2014 RBR also provides updates regarding the measles-mumps-rubella, live attenuated influenza, and human papillomavirus vaccines. CONCLUSION: The 2014 RBR is the most recent update of a longstanding evidence-based, practical knowledge translation tool with related Web-based resources to be used by both health care professionals and parents for preventive health care during early childhood. The 2014 RBR is endorsed by the Canadian Paediatric Society, the College of Family Physicians of Canada, and the Dietitians of Canada. National and Ontario versions of the RBR are available in English and French.

Vitamin D Supplementation for Childhood Asthma: A Systematic Review and Meta-Analysis.

IMPORTANCE: There is growing evidence that vitamin D plays a role in the pathogenesis of asthma but it is unclear whether supplementation during childhood may improve asthma outcomes. OBJECTIVES: The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of vitamin D supplementation as a treatment or adjunct treatment for asthma. DATA SOURCES: We searched MEDLINE, Embase, CENTRAL, and CINAHL through July 2014. STUDY SELECTION: We included RCTs that evaluated vitamin D supplementation in children versus active control or placebo for asthma. DATA EXTRACTION AND SYNTHESIS: One reviewer extracted data and one reviewer verified data accuracy. We qualitatively summarized the main results of efficacy and safety and meta-analyzed data on comparable outcomes across studies. We used GRADE for strength of evidence. MAIN OUTCOME MEASURES: Main planned outcomes measures were ED visits and hospitalizations. As secondary outcomes, we examined measures of asthma control, including frequency of asthma exacerbations, asthma symptom scores, measures of lung function, ß2-agonist use and daily steroid use, adverse events and 25-hydroxyvitamin D levels. RESULTS: Eight RCTs (one parallel, one crossover design) comprising 573 children aged 3 to 18 years were included. One study (moderate-quality, n = 100) reported significantly less ED visits for children treated with vitamin D. No other studies examined the primary outcome (ED visits and hospitalizations). There was a reduced risk of asthma exacerbations in children receiving vitamin D (low-quality; RR 0.41, 95% CI 0.27 to 0.63, 3 studies, n = 378). There was no significant effect for asthma symptom scores and lung function. The serum 25(OH)D level was higher in the vitamin D group at the end of the intervention (low-quality; MD 19.66 nmol/L, 95% CI 5.96 nmol/L to 33.37 nmol/L, 5 studies, n = 167). LIMITATIONS: We identified a high degree of clinical diversity (interventions and outcomes) and methodological heterogeneity (sample size and risk of bias) in included trials. CONCLUSIONS AND RELEVANCE: Randomized controlled trials provide some low-quality evidence to support vitamin D supplementation for the reduction of asthma exacerbations. Evidence on the benefits of vitamin D supplementation for other asthma-related outcomes in children is either limited or inconclusive. We recommend that future trials focus on patient-relevant outcomes that are comparable across studies, including standardized definitions of asthma exacerbations.

Prevalence of vitamin D insufficiency among healthy school-age Cree children.

BACKGROUND: First Nations children are at higher risk for vitamin D deficiency and rickets. OBJECTIVE: To assess the prevalence of vitamin D deficiency and the correlations between fat mass, parathyroid hormone and dietary habits with serum vitamin D level in a random sample of Cree children eight to 14 years of age. METHODS: Serum 25-hydroxyvitamin D (25[OH]D) levels and additional information regarding anthropometrics and dietary habits were obtained from participants in two Cree communities. Vitamin D deficiency and insufficiency was defined as serum 25(OH)D levels <30 nmol/L and <50 nmol/L, respectively. Proportions to estimate the vitamin D status were weighted to account for the complex sampling design, and Pearson's correlation coefficients were used to estimate the associations of milk and fish intake, parathyroid hormone and fat mass with serum 25(OH)D levels. RESULTS: Data from 52 healthy Cree children (mean [± SD] age 11.1±2.0 years; 27 boys) were included in the analyses. The median serum 25(OH)D level was 52.4 nmol/L (range 22.1 nmol/L to 102.7 nmol/L). Forty-three percent (95% CI 29% to 58%) and 81% (95% CI 70% to 92%) of Cree children had vitamin D levels <50 nmol/L and <75 nmol/L, respectively. Vitamin D intake was positively associated with serum 25(OH)D levels. Obese children had lower vitamin D levels; however, the difference was nonsignificant. CONCLUSION: There may be a substantial proportion of Cree children who are vitamin D deficient. Increasing age, lower dietary vitamin D intake and, possibly, higher body mass index were associated with decreased vitamin D levels; however, causality cannot be inferred.

HISTORIQUE: Les enfants des Premières nations sont plus vulnérables à une insuffisance en vitamine D et au rachitisme. OBJECTIF: Évaluer la prévalence de carence en vitamine D et les corrélations entre, d'une part, la masse grasse, la parathormone et les habitudes alimentaires et, d'autre part, le taux sérique de vitamine D dans un échantillon d'enfants cris de huit à 14 ans sélectionnés au hasard. MÉTHODOLOGIE: On a obtenu le taux sérique de 25(OH)D des participants provenant de deux communautés cries, qui ont également fourni de l'information sur leurs données anthropométriques et leurs habitudes alimentaires. La carence et l'insuffisance en vitamine D étaient définies par des taux sériques de 25(OH)D inférieurs à 30 nmol/L et à 50 nmol/L, respectivement. Les proportions pour évaluer le taux de vitamine D ont été pondérées pour tenir compte de la méthodologie complexe de l'échantillon, et les coefficients de corrélation de Pearson ont permis d'évaluer les associations entre le taux sérique de 25(OH)D, d'une part, et la consommation de lait et de poisson, la parathormone et la masse grasse, d'autre part. RÉSULTATS: Les analyses incluaient les données provenant de 52 enfants cris en bonne santé (âge moyen [± ÉT] de 11,1±2,0 ans; 27 garçons). Le taux sérique médian de 25(OH)D s'élevait à 52,4 nmol/L (plage de 22,1 nmol/L à 102,7 nmol/L). Quarantetrois pour cent (95 % IC 29 % à 58 %) et 81 % (95 % IC 70 % à 92 %) des enfants cris présentaient un taux de vitamine D inférieur à 50 nmol/L et à 75 nmol/L, respectivement. La consommation de vitamine D était associée de manière positive au taux sérique de 25(OH)D. Les enfants obèses présentaient des taux de vitamine D plus faibles, mais la différence n'était pas significative. CONCLUSION: Une forte proportion d'enfants cris présente peutêtre une carence en vitamine D. L'âge, une moins grande consommation alimentaire de vitamine D et, peutêtre, un indice de masse corporelle plus élevé étaient liés à un taux moins élevé de vitamine D. Cependant, on ne peut en induire une causalité.

Prevalence of vitamin D insufficiency and associated factors among Canadian Cree: a cross-sectional study.

OBJECTIVES: Aboriginal peoples affected by a nutrition transition and living at high latitudes are among the ethnic groups most at risk of vitamin D deficiency. The objectives of this study were to determine the prevalence of meeting predefined cut-off concentrations of vitamin D and to examine associated factors among James Bay Cree aged ≥ 15 years. METHODS: A cross-sectional study was conducted between the months of May and September from 2005 to 2009. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were determined by radioimmunoassay. Anthropometrics were measured and additional information on socio-demographic characteristics, lifestyle and dietary habits was obtained using questionnaires. A logistic regression model predicting vitamin D insufficiency (<50 nmol/L) included known covariates. RESULTS: Data were obtained from 944 Cree (406 men (43%); mean age 37.4 years), with an effective participation rate of 49% among women and 41% among men. Mean serum 25(OH)D concentrations (nmol/L) by gender were 52.9 (95% CI 51.4-54.5) in men and 47.5 (95% CI 46.2-48.9) in women, and by age group were 46.0 (95% CI 44.9-48.9) in those 15-39 years and 59.6 (95% CI 57.9-61.4) in those ≥ 40 years of age. Overall, 5.8%, 42.6%, 40.0%, and 11.7% of the participants had 25(OH)D concentrations <30, 30-49.9, 50-74.9 and ≥ 75 nmol/L, respectively. Female gender, obesity, younger age, spring, low fish and milk intake, and low vigorous physical activity predicted vitamin D insufficiency (all p<0.05). CONCLUSION: The vitamin D status in Eastern James Bay Cree is suboptimal with nearly half of the population having insufficient concentrations for optimum bone health.