Repeated faecal occult blood testing is associated with decreased advanced colorectal cancer risk: A population-based study.

OBJECTIVE: To evaluate the association between repeated faecal occult blood testing and advanced colorectal cancer risk at population level in Canada. METHODS: A retrospective cohort study of all Ontario residents aged 56-74 diagnosed with colorectal cancer from 1 April 2007 to 31 March 2010, identified using health administrative data. The primary outcome was stage IV colorectal cancer, and primary exposure was faecal occult blood testing use within five years prior to colorectal cancer diagnosis. Patients were categorized into four mutually exclusive groups based on their exposure to faecal occult blood testing in the five years prior to colorectal cancer diagnosis: none, pre-diagnostic, repeated, and sporadic. Logistic regression was utilized to adjust for confounders. RESULTS: Of 7753 patients (median age 66, interquartile range 61-70, 62% male) identified, 1694 (22%) presented with stage I, 2056 (27%) with stage II, 2428 (31%) with stage III, and 1575 (20%) with stage IV colorectal cancer. There were 4092 (53%) with no record of prior faecal occult blood testing, 1485 (19%) classified as pre-diagnostic, 1693 (22%) as sporadic, and 483 (6%) as repeated faecal occult blood testing. After adjusting for confounders, patients who had repeated faecal occult blood testing were significantly less likely to present with stage IV colorectal cancer at diagnosis (Odds ratio 0.46, 95% Confidence Interval 0.34-0.62) than those with no prior faecal occult blood testing. CONCLUSIONS: Repeated faecal occult blood testing is associated with a decreased risk of advanced colorectal cancer. Our findings support the use of organized screening programmes that employ repeated faecal occult blood testing to improve colorectal cancer outcomes at population level.

Can Chemotherapy-Related Acute Care Visits Be Accurately Identified in Administrative Data?

PURPOSE: There is increasing interest in using administrative data to examine treatment-related complications that lead to emergency department (ED) visits or hospitalizations (H). The purpose of this study was to evaluate the reliability of billing codes for identifying chemotherapy-related acute care visits (CRVs) among women with early-stage breast cancer. MATERIALS AND METHODS: The cohort was identified by using deterministically linked health databases and consisted of women who were diagnosed with early-stage breast cancer who started adjuvant chemotherapy between 2007 and 2009 in Ontario, Canada. A random sample of 496 patient cases was chosen as the validation cohort. Sensitivity (SN) and specificity (SP) were calculated for three scenarios: chemotherapy-related ED visit, chemotherapy-related H, and febrile neutropenia (FN)-related visit. For FN-related visits, three definitions were considered: general, moderate, and strict. RESULTS: The administrative cohort consisted of 8,359 patients, 43.4% of whom had at least one ED or H, including 1,496 women who had multiple visits that resulted in 6,293 unique visits. Of these, 73.1% were considered CRVs. The algorithm performed well in identifying CRVs that included H either from ED (SN, 90%; SP, 100%) or directly from home (SN, 91%; SP, 93%), but less well for ED visits that did not result in H (SN, 65%; SP, 80%). Depending on which FN algorithm was used, 4.8% to 24% of visits were considered related. The moderate FN algorithm provided the best tradeoff between SN (69% to 97%) and SP (83% to 98%). CONCLUSION: Administrative data can be valuable in evaluating chemotherapy-related serious events. Algorithm validation in other cohorts is needed.

Setting Quality Improvement Priorities for Women Receiving Systemic Therapy for Early-Stage Breast Cancer by Using Population-Level Administrative Data.

Purpose Routine evaluation of quality measures (QMs) can drive improvement in cancer systems by highlighting gaps in care. Targeting quality improvement at QMs that demonstrate substantial variation has the potential to make the largest impact at the population level. We developed an approach that uses both variation in performance and number of patients affected by the QM to set priorities for improving the quality of systemic therapy for women with early-stage breast cancer (EBC). Patients and Methods Patients with EBC diagnosed from 2006 to 2010 in Ontario, Canada, were identified in the Ontario Cancer Registry and linked deterministically to multiple health care databases. Individual QMs within a panel of 15 QMs previously developed to assess the quality of systemic therapy across four domains (access, treatment delivery, toxicity, and safety) were ranked on interinstitutional variation in performance (using interquartile range) and the number of patients who were affected; then the two rankings were averaged for a summative priority ranking. Results We identified 28,427 patients with EBC who were treated at 84 institutions. The use of computerized physician electronic order entry for chemotherapy, emergency room visits or hospitalizations during chemotherapy, and timely receipt of chemotherapy were identified as the QMs that had the largest potential to improve quality of care at a system level within this cohort. Conclusion A simple ranking system based on interinstitutional variation in performance and patient volume can be used to identify high-priority areas for quality improvement from a population perspective. This approach is generalizable to other health care systems that use QMs to drive improvement.

Printed educational messages fail to increase use of thiazides as first-line medication for hypertension in primary care: a cluster randomized controlled trial [ISRCTN72772651].

BACKGROUND: Evidence on the effectiveness of printed educational messages in contributing to increasing evidence-based clinical practice is contradictory. Nonetheless, these messages flood physician offices, in an attempt to promote treatments that can reduce costs while improving patient outcomes. This study evaluated the ability of printed educational messages to promote the choice of thiazides as the first-line treatment for individuals newly diagnosed with hypertension, a practice supported by good evidence and included in guidelines, and one which could reduce costs to the health care system. METHODS: The study uses a pragmatic, cluster randomized controlled trial (randomized by physician practice group). SETTING: The setting involves all Ontario general/family practice physicians. Messages advising the use of thiazides as the first-line treatment of hypertension were mailed to each physician in conjunction with a widely read professional newsletter. Physicians were randomized to receive differing versions of printed educational messages: an "insert" (two-page evidence-based article) and/or one of two different versions of an "outsert" (short, directive message stapled to the outside of the newsletter). One outsert was developed without an explicit theory and one with messages developed targeting factors from the theory of planned behaviour or neither (newsletter only, with no mention of thiazides). The percentage of patients aged over 65 and newly diagnosed with hypertension who were prescribed a thiazide as the sole initial prescription medication. The effect of the intervention was estimated using a logistic regression model estimated using generalized estimating equation methods to account for the clustering of patients within physician practices. RESULTS: Four thousand five hundred four physicians (with 23,508 patients) were randomized, providing 97 % power to detect a 5 % absolute increase in prescription of thiazides. No intervention effect was detected. Thiazides were prescribed to 27.6 % of the patients who saw control physicians, 27.4 % for the insert, 26.8 % for the outsert and 28.3 % of the patients who saw insert + outsert physicians, p = 0.54. CONCLUSIONS: The study conclusively failed to demonstrate any impact of the printed educational messages on increasing prescribing of thiazide diuretics for first-line management of hypertension. TRIAL REGISTRATION: ISRCTN72772651.

Incidence of Diabetes in Colorectal Cancer Survivors.

BACKGROUND: A higher risk of colorectal cancer (CRC) in patients with diabetes has been well documented. However, little is known regarding diabetes incidence in CRC survivors. This may have substantial impact on CRC survivorship care as well as enhancing the understanding of the interplay between the two diseases. We explored whether the incidence of diabetes was higher among patients with CRC than matched control subjects. METHODS: Using population-based data from Ontario, Canada, we generated a dataset comprising 39 707 incident CRC cases and 198 535 age- and sex-matched control subjects (1:5) dating from April 2002 to March 2010. We used cause-specific hazard models to estimate the hazard ratios (HRs) for diabetes overall and in subgroups stratified by receipt of systemic chemotherapy, diagnosis of metastatic disease, and site of cancer. RESULTS: During a mean follow-up of 4.81 years, the association between CRC and diabetes varied: The rate of developing diabetes was 53% higher among CRC patients compared with control subjects in the first year postdiagnosis (HR = 1.53, 95% confidence interval [CI] = 1.42 to 1.64) and remained increased by 19% in the fifth year postdiagnosis (HR = 1.19, 95% CI = 1.05 to 1.35). Findings were similar in subgroups of patients who had colon cancer, received systemic chemotherapy, or had no evidence of metastasis. CONCLUSION: We found that CRC patients were statistically significantly more likely to develop subsequent diabetes than persons without CRC for up to five years after the diagnosis. Our study suggests that active screening and counseling regarding modifiable risk factors may be warranted in this high-risk group.

Population-based assessment of the outcomes in patients with postcolonoscopy colorectal cancers.

OBJECTIVE: The potential for cancers to not be detected on colonoscopy is increasingly recognised, but little is known about patient outcomes. The objective of this study was to assess the outcomes of patients diagnosed with postcolonoscopy colorectal cancers (PCCRCs). DESIGN: We conducted a population-based retrospective cohort study, including all patients diagnosed with colorectal cancer (CRC) in Ontario, Canada from 2003 to 2009. Patients were categorised into three groups: DETECTED (diagnosed within 6 months of first colonoscopy), PCCRC (diagnosed 6-36 months after first colonoscopy) or NOSCOPE (no colonoscopy within 36 months of diagnosis). Univariate and multivariable analyses were conducted to study overall survival, surgical treatment, emergency presentation and surgical complications. RESULTS: Overall, 45 104 patients were included, with 2804 being classified as having a PCCRC. Compared with the DETECTED group, PCCRC was associated with a significantly higher likelihood of stage IV disease (17.2% vs 12.9%), worse overall survival (5 year OS: 60.8% vs 68.3%, p<0.0001; adjusted HR: 1.25, 95% CI 1.17 to 1.32, p<0.0001), a higher likelihood of emergency presentation (OR: 2.86, 95% CI 2.56 to 3.13, p<0.001) and lower likelihood of surgical resection (OR: 0.61, 95% CI 0.55 to 0.67, p<0.001). However, patients with PCCRC had significantly better outcomes than those in the NOSCOPE group (stage IV: 37.1%, 5 year OS: 38.9%) CONCLUSIONS: Compared with CRC detected by colonoscopy, PCCRCs are associated with a higher risk of emergent presentation, a lower likelihood of surgical resection and most notably, significantly worse oncological outcomes. However, they have better outcomes than patients with no recent colonoscopy.

Use and impact of intermittent versus continuous systemic treatment strategies in metastatic colorectal cancer in routine practice.

BACKGROUND: Randomized trials have shown that intermittent treatment may reduce toxicity without compromising survival in patients with metastatic colorectal cancer (mCRC). A population-based study examined patterns of use of chemotherapy-free intervals (CFIs) in routine practice in Ontario and their impact on survival and toxicity. METHODS: Patients treated with first-line intravenous chemotherapy for mCRC in Ontario between 2007 and 2009 were identified from administrative data. A CFI was defined as more than 56 days between 2 chemotherapy doses. A propensity score analysis was used to compare the survival of patients with CFIs and patients without CFIs, stratified by the type of first-line treatment: irinotecan (IRI), irinotecan plus bevacizumab (IRI-B), and oxaliplatin (OX). Toxicity was estimated on the basis of the rate of emergency room visits and hospitalizations. RESULTS: There were 1989 patients who started first-line chemotherapy for mCRC in Ontario between 2007 and 2009, and 489 (25%) had at least 1 CFI. The median time to the first CFI was 155 days (interquartile range, 82-217 days). There was no difference in survival for the propensity score-matched patients with or without CFIs in the IRI (hazard ratio [HR], 0.93; P = .70) and OX groups (HR, 0.73; P = .06). Survival was worse in the CFI group for patients treated with IRI-B (HR, 1.28; P = .03). Toxicity was lower for patients with at least 1 CFI (0.17 vs 0.25 acute visits per person-month of treatment, P = .007), although the magnitude varied with the treatment type. CONCLUSIONS: Intermittent treatment strategies are being used in routine practice for patients with mCRC. The impact on survival and toxicity varies with the type of first-line chemotherapy.

Mailed participant reminders are associated with improved colonoscopy uptake after a positive FOBT result in Ontario's ColonCancerCheck program.

BACKGROUND: Timely follow-up of fecal occult blood screening with colonoscopy is essential for achieving colorectal cancer mortality reduction. This study evaluates the effectiveness of two ongoing interventions designed to improve colonoscopy uptake after a positive fecal occult blood test (FOBT) result within Ontario's population-wide ColonCancerCheck program. The first was a revision of mailed FOBT lab results to physicians to explicitly define a positive FOBT and to recommend colonoscopy. The second was a letter to participants informing them of the positive FOBT and urging them to seek appropriate follow-up. METHODS: Prospective cohort study using Ontario's ColonCancerCheck program data sets (2008-2011), linked to provincial administrative health databases. Crude rate ratios were calculated to assess determinants of colonoscopy uptake among an Ontario-wide FOBT-positive cohort with rolling enrolment, followed from October 2008 through February 2011. Segmented time-series regression was used to assess the average additional change in colonoscopy uptake after FOBT-positive status following the introduction of two ongoing interventions among the same cohort. RESULTS: A notification mailed directly to FOBT-positive screening participants was observed to increase colonoscopy uptake, beyond the modest average underlying increase throughout the study period, by an average of 3% per month (multivariable-adjusted RR: 1.03, 95% CI: 1.00-1.06). However, revision of the existing FOBT result notification to physicians was observed to have no effect. CONCLUSIONS: Direct participant notification of a positive FOBT result improved adherence with follow-up colonoscopy in Ontario's population-wide ColonCancerCheck program. Further participant-directed interventions may be effective means of maximizing adherence in population-wide screening.

Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices.

BACKGROUND: ColonCancerCheck (CCC), Ontario's organized colorectal cancer (CRC) screening program, uses guaiac fecal occult blood testing (gFOBT). To reduce CRC-related mortality, persons with a positive gFOBT must have colonoscopy. We identified factors associated with failure to have colonoscopy within 6months of a positive gFOBT. METHODS: Population-based, retrospective cohort analysis of CCC participants with positive gFOBT (April 2008 to December 2009) using health administrative data. Patient, physician and health care utilization factors associated with a lack of follow-up colonoscopy were identified using descriptive and multivariate analyses. RESULTS: There were 21,839 participants with a positive gFOBT; 14,091 (64%) had colonoscopy within 6months. The strongest factors associated with failure to follow-up were recent colonoscopy (in 2years prior vs. >10years or never, OR: 4.31, 95% C.I.: 3.82, 4.86), as well as repeat gFOBT (OR: 6.08, 95% C.I.: 5.46, 6.78) and hospital admission (OR: 4.35, 95% C.I.: 3.57, 5.26) in the follow-up period. CONCLUSION: In the first 18months of the CCC Program, 1/3 of those with a positive gFOBT did not have colonoscopy within 6months. Identification of potentially modifiable factors associated with failure to follow up lay the groundwork for interventions to address this critical quality gap.

Population-based assessment of emergency room visits and hospitalizations among women receiving adjuvant chemotherapy for early breast cancer.

PURPOSE: Adjuvant chemotherapy is considered standard care for patients with lymph node (LN) -positive and high-risk LN-negative early breast cancer (EBC). Although chemotherapy-associated toxicities are documented in clinical trials, the impact of toxicities on emergency room (ER) visits and hospitalizations (ER + Hs) at a population level with contemporary chemotherapy is unknown. We undertook a population-based study of ER + Hs in patients with EBC receiving adjuvant chemotherapy compared with noncancer controls (NCCs). METHODS: All patients diagnosed with EBC between January 2007 and December 2009 in Ontario, Canada, were identified from the Ontario Cancer Registry. Patient records were linked deterministically to provincial health care databases to provide comprehensive medical follow-up. All patients received ≥ one cycle of adjuvant chemotherapy. Patient cases of EBC (n = 8,359) were matched to NCCs (n = 8,359) on age, comorbidity, and geographic location. ER + Hs within 30 days of chemotherapy were identified. If the primary reason for the visit was a common chemotherapy toxicity, the visit was considered chemotherapy associated. All-cause and chemotherapy-associated visits were compared between patient cases and controls. Logistic regression models were used to identify covariates associated with ER + Hs. RESULTS: The proportion of patients with at least one ER + H was significantly higher in patients with EBC undergoing chemotherapy compared with NCCs (43.4% v 9.4%; P < .001). Patients with EBC were also more likely to have multiple ER + Hs (17.9% v 2.4%; P < .001). On multivariable analysis, comorbidity, receiving a regimen containing docetaxel, and certain geographic regions were associated with increased odds of ER + Hs. CONCLUSION: ER + Hs are common among patients with EBC receiving chemotherapy and significantly higher than among controls. This represents a potential opportunity for quality improvement.

Printed educational messages aimed at family practitioners fail to increase retinal screening among their patients with diabetes: a pragmatic cluster randomized controlled trial [ISRCTN72772651].

BACKGROUND: Evidence of the effectiveness of printed educational messages in narrowing the gap between guideline recommendations and practice is contradictory. Failure to screen for retinopathy exposes primary care patients with diabetes to risk of eye complications. Screening is initiated by referral from family practitioners but adherence to guidelines is suboptimal. We aimed to evaluate the ability of printed educational messages aimed at family doctors to increase retinal screening of primary care patients with diabetes. METHODS: Design: Pragmatic 2×3 factorial cluster trial randomized by physician practice, involving 5,048 general practitioners (with 179,833 patients with diabetes). Setting: Ontario family practitioners. Interventions: Reminders (that retinal screening helps prevent diabetes-related vision loss and is covered by provincial health insurance for patients with diabetes) with prompts to encourage screening were mailed to each physician in conjunction with a widely-read professional newsletter. Alternative printed materials formats were an 'outsert' (short, directive message stapled to the outside of the newsletter), and/or a two-page, evidence-based article ('insert') and a pre-printed sticky note reminder for patients. Main Outcome Measure: A successful outcome was an eye examination (which includes retinal screening) provided to a patient with diabetes, not screened in the previous 12 months, within 90 days after visiting a family practitioner. Analysis accounted for clustering of doctors within practice groups. RESULTS: No intervention effect was detected (eye exam rates were 31.6% for patients of control physicians, 31.3% for the insert, 32.8% for the outsert, 32.3% for those who received both, and 31.2% for those who received both plus the patient reminder with the largest 95% confidence interval around any effect extending from -1.3% to 1.1%). CONCLUSIONS: This large trial conclusively failed to demonstrate any impact of printed educational messages on screening uptake. Despite their low cost, printed educational messages should not be routinely used in attempting to close evidence-practice gaps relating to diabetic retinopathy screening. TRIAL REGISTRATION: ISRCTN72772651.

Practice patterns and trends in the use of medical therapy in patients undergoing percutaneous coronary intervention in Ontario.

BACKGROUND: Clinical guidelines emphasize medical therapy as the initial approach to the management of patients with stable coronary artery disease (CAD). However, the extent to which medical therapy is applied before and after percutaneous coronary intervention (PCI) in contemporary clinical practice is uncertain. We evaluated medication use for patients with stable CAD undergoing PCI, and assessed whether the COURAGE study altered medication use in the Canadian healthcare system. METHODS AND RESULTS: A population-based cohort of 23 680 older patients >65 years old) with stable CAD undergoing PCI in Ontario between 2003 and 2010 was assembled. Optimal medical therapy (OMT) was defined as prescription for a ß-blocker, statin, and either angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker in the 90 days before PCI, and the same medications plus thienopyridine 90 days following PCI. Prior to PCI, 8023 (33.9%) patients were receiving OMT, 11 891 (50.2%) were on suboptimal therapy, and 3766 (15.9%) were not prescribed any medications of interest. There was significant improvement in medical therapy following PCI (OMT: 11 149 [47.1%], suboptimal therapy: 11 591 [48.9%], and none: 940 [4.0%], P<0.001). Utilization rate of OMT reduced significantly after the publication of COURAGE (34.9% before versus 32.8% after, P<0.001). Similarly, the rate of OMT following PCI was lower in the period after publication of COURAGE (47.3% before versus 46.9% after, P<0.001). CONCLUSIONS: OMT was prescribed in about 1 in 3 patients prior to PCI and less than half after PCI. In contrast to the anticipated impact of COURAGE, we found lower rates of medication use in PCI patients after its publication.

Relationship between care gaps and projected life expectancy after acute myocardial infarction.

BACKGROUND: Higher-risk patients may not receive evidence-based therapy because of limited life expectancy, which is a composite measure that encompasses many patient factors, including age, frailty, and comorbidities. In this study, we evaluated the extent to which treatment care gaps can be explained by a difference in projected life expectancy. METHODS AND RESULTS: An observational cohort study was conducted on acute myocardial infarction patients hospitalized in Ontario, Canada. Projected life expectancy was estimated using actual survival data with extrapolation using proportional hazard models adjusting for important covariates. The relationship between projected life expectancy with statins and reperfusion therapy was examined using generalized linear models. Among the 7001 acute myocardial infarction patients, 84.3% were prescribed statins and 72.9% were treated with reperfusion therapy. When projected life expectancy was <10 years, the likelihood of receiving either treatment declined progressively with reduction in life expectancy (P<0.001). At the 25th percentile of projected life expectancies, the likelihood of receiving a statin decreased by 1.4% (95% confidence interval, 1.0-1.8%), and acute reperfusion therapy decreased by 2.6% (95% confidence interval, 1.8-3.3%) for each year decline in projected life expectancy. CONCLUSIONS: Life expectancy of a patient strongly influences evidence-based treatment in acute myocardial infarction. It was seen not only among patients with limited life expectancies but also among those with many years to live. Treatment care gaps may reflect clinicians' synthesis about frailty and life-expectancy gains.

Using physician-linked mailed invitations in an organised colorectal cancer screening programme: effectiveness and factors associated with response.

OBJECTIVES: A central tenet of organised cancer screening is that all persons in a target population are invited. The aims of this study were to identify participant and physician factors associated with response to mailed physician-linked invitations (study 1) and to evaluate their effectiveness in an organised colorectal cancer (CRC) screening programme (study 2). DESIGN AND SETTING: 2 studies (study 1-cohort design and study 2-matched cohort design, comprising study 1 participants and a matched control group) were conducted in the context of Ontario's organised province-wide CRC screening programme. PARTICIPANTS: 102 family physicians and 11 302 associated eligible patients from a technical evaluation ('the Pilot') of large-scale mailed invitations for CRC screening were included. Matched controls were randomly selected using propensity scores from among eligible patients associated with family physicians in similar practice types as the Pilot physicians. INTERVENTION: Physician-linked mailed invitation to have CRC screening. OUTCOMES: Uptake of faecal occult blood test (FOBT) within 6 months of mailed invitation (primary) and uptake of FOBT or colonoscopy within 6 months of mailed invitation (secondary). RESULTS: Factors significantly associated with uptake of FOBT included prior FOBT use, older participant age, greater participant comorbidity and having a female physician. In the matched analysis, Pilot participants were more likely to complete an FOBT (22% vs 8%, p<0.0001) or an FOBT or colonoscopy (25% vs 11%, p<0.0001) within 6 months of mailed invitation than matched controls. The number needed to invite to screen one additional person was 7. CONCLUSIONS: Centralised large-scale mailing of physician-linked invitations is feasible and effective in the context of organised CRC screening.

Rates and risk factors for prolonged opioid use after major surgery: population based cohort study.

OBJECTIVE: To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery. DESIGN: Population based retrospective cohort study. SETTING: Acute care hospitals in Ontario, Canada, between 1 April 2003 and 31 March 2010. PARTICIPANTS: 39,140 opioid naïve patients aged 66 years or older who had major elective surgery, including cardiac, intrathoracic, intra-abdominal, and pelvic procedures. MAIN OUTCOME MEASURE: Prolonged opioid use after discharge, as defined by ongoing outpatient prescriptions for opioids for more than 90 days after surgery. RESULTS: Of the 39,140 patients in the entire cohort, 49.2% (n=19,256) were discharged from hospital with an opioid prescription, and 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Following risk adjustment with multivariable logistic regression modelling, patient related factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities (diabetes, heart failure, pulmonary disease), and use of specific drugs preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). The type of surgical procedure was also highly associated with prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively). CONCLUSIONS: Approximately 3% of previously opioid naïve patients continued to use opioids for more than 90 days after major elective surgery. Specific patient and surgical characteristics were associated with the development of prolonged postoperative use of opioids. Our findings can help better inform understanding about the long term risks of opioid treatment for acute postoperative pain and define patient subgroups that warrant interventions to prevent progression to prolonged postoperative opioid use.

Duration of preoperative ß-blockade and outcomes after major elective noncardiac surgery.

BACKGROUND: Although practice guidelines recommend that perioperative ß-blockade be initiated at least several days to weeks before noncardiac surgery is performed, the minimum required period of preoperative therapy is unclear. METHODS: Population-based administrative databases were used to conduct a cohort study of 48,103 patients aged ≥ 66 years who underwent major elective noncardiac surgery in Ontario, Canada and received preoperative ß-blocker therapy. We used multivariable logistic regression to determine the association of duration of preoperative ß-blocker treatment (classified as 1-7 days, 8-30 days, and ≥ 31 days) with 30-day mortality, 30-day myocardial infarction (MI), 30-day ischemic stroke, and 1-year mortality. RESULTS: The duration of preoperative ß-blocker treatment was 1-7 days in 1105 patients (2.3%), 8-30 days in 2639 patients (5.5%), and ≥ 31 days in 44,269 patients (92.0%). Compared with ≥ 31 days of preoperative therapy, 1-7 days of therapy was associated with increased 30-day mortality (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.03-2.16; P = 0.03], whereas 8-30 days of therapy was not (OR, 0.95; 95% CI, 0.69-1.31; P = 0.77). One to 7 days of preoperative therapy was not significantly associated with 1-year mortality (OR, 1.06; 95% CI, 0.84-1.35; P = 0.62), 30-day MI (OR, 1.26; 95% CI, 0.92-1.71; P = 0.15), or 30-day ischemic stroke (OR, 1.37; 95% CI, 0.64-2.94; P = 0.41). CONCLUSIONS: Initiation of ß-blocker therapy 1-7 days before noncardiac surgery is associated with increased 30-day mortality. The findings merit further evaluation by randomized trials.

A population-based description of atrial fibrillation in the emergency department, 2002 to 2010.

STUDY OBJECTIVE: We aimed to describe the demographics, care, and outcomes of patients with atrial fibrillation in the emergency department (ED), as well as temporal changes over time. METHODS: In this retrospective cohort study, we used a province-wide database to identify all adult patients who were treated in a nonpediatric ED in the province of Ontario with a primary diagnosis of atrial fibrillation, April 2002 to March 2010. We determined the frequency and rate of ED visits and assessed patient demographics, ED care, and outcomes, both overall and by year. RESULTS: During the 8-year study period, 113,786 patients made 143,003 ED visits for atrial fibrillation, accounting for 0.5% of all ED visits. The annual number of ED visits increased from 15,931 to 20,168 (29.4%; 95% confidence interval [CI] 28.7% to 30.1%) between 2002 and 2010, whereas the crude rate increased from 172 per 100,000 to 195 per 100,000 persons. Median age was 72.0 years (Interquartile range 61.0 to 80.0 years) and 50.8% were women, which did not change significantly during the study period. The percentage of index ED visits with a physician billing for cardioversion increased from 6.3% (95% CI 5.9% to 6.7%) to 11.8% (95% CI 11.3% to 12.3%). Although the percentage of patients with a CHADS2 score greater than or equal to 2 increased from 49.3% (95% CI 48.4% to 50.2%) to 53.6% (95% CI 52.9% to 54.4%) and high-acuity ED triage scores increased from 41.1% (95% CI 40.2% to 42.0%) to 62.5% (95% CI 61.7% to 63.2%), hospital admissions decreased from 48.1% (95% CI 47.3% to 49.0%) to 38.4% (95% CI 37.6% to 39.2%). Thirty-day mortality was 3.3% (95% CI 3.2% to 3.4%) and showed a slight downward trend during the study period (P=.05), whereas subsequent hospitalizations within 30 days for atrial fibrillation or stroke (2.8%; 95% CI 2.7% to 2.9%) and repeated ED visits (7.3%; 95% CI 7.1% to 7.4%) remained unchanged. CONCLUSION: The number of ED visits for atrial fibrillation increased markedly during an 8-year period. Although it appears that slightly higher-risk patients are being treated in the province's EDs, fewer patients are being admitted to the hospital, and mortality rates have not increased.

Socioeconomic status and care after stroke: results from the Registry of the Canadian Stroke Network.

BACKGROUND AND PURPOSE: Socioeconomic status is inversely associated with mortality after stroke; however, the reasons behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and medication adherence vary with neighborhood income. METHODS: We conducted a cohort study of 11 050 patients with ischemic stroke or transient ischemic attack admitted to any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We used multivariable analyses to assess whether differences in stroke care and medication adherence existed across income groups after adjustment for age, sex, stroke severity, and comorbid conditions. RESULTS: Higher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates were small. There was no difference across income quintiles in the use of postdischarge homecare services or in adherence to antihypertensive, antithrombotic, or lipid-lowering medications. CONCLUSIONS: Higher income is associated with improvements in some aspects of stroke care delivery. However, the magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed association between socioeconomic status and survival after stroke.