Effect of older maternal age on birth outcomes in twin pregnancies: a population-based study.

OBJECTIVE: We compared perinatal mortality, preterm birth (<37, <33 and <28 weeks), small for gestational age (SGA), Apgar score (<4), mechanical ventilation (1 days) and prolonged neonatal intensive care unit (NICU) hospitalization (13 days) between twins of 25 to 34 and >35-year-old women. Further, we examined whether older maternal age effects were modified by parity or otherwise affected by chorionicity. STUDY DESIGN: We carried out a population-based retrospective cohort study including all twin births in British Columbia (BC), Canada, from 1999 to 2003. The BC perinatal database registry was used to obtain clinical, behavioral and demographic data. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated using generalized estimating equation models. RESULT: Overall, twins of older women were more likely to be born preterm (<37 weeks), but not very or extremely preterm (<33 weeks). These twins were not at increased risk of perinatal death, mechanical ventilation or were not SGA compared with twins of younger women. Twins of older primiparous women did not have an elevated risk of NICU hospitalization; twins born to older multiparous women had higher risk (OR=1.8; 95% CI: 1.2 to 2.6). Analyses restricted to opposite-sex (dichorionic) twins showed that perinatal death, mechanical ventilation and very preterm birth occur less likely among older women (OR=0.2 (95% CI: 0.0 to 0.8), OR=0.3 (95% CI: 0.1 to 0.7) and OR=0.4 (95% CI: 0.2 to 0.7), respectively). Further, the risk of late preterm birth was increased and NICU hospitalization was reduced among opposite-sex twins born to older compared with younger primiparous women (OR=1.9 (95% CI: 1.3 to 2.8) and OR=0.2 (95% CI: 0.1 to 0.5), respectively). CONCLUSION: Twins of older mothers did not have an elevated risk for most adverse birth outcomes, except for late preterm birth. Risks of neonatal care admission may be elevated among older multiparous women.

The quick and the dead: "managing" inpatient care in British Columbia hospitals, 1969-1995/96.

OBJECTIVE: To examine changes in hospital use in British Columbia during a decade of capacity reductions. DATA SOURCES/STUDY SETTING: The data used are all separation records for British Columbia hospitals for the years 1969, 1978, 1985/86, 1993/94, and 1995/96. Separation records include acute care, rehabilitation, extended care, and surgical day care hospital encounters in British Columbia that were concluded during the years of interest. STUDY DESIGN: Analyses were based on per capita use of services for five-year age groups of the population to ages 90+; the emphasis was on looking at changes in the use of specific types of hospital services over the 26 years of study, with a particular focus on the most recent decade. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from hospital separations files owned by the British Columbia Ministry of Health and housed at the Centre for Health Services and Policy Research. All separation records for the years of interest were included in the study. PRINCIPAL FINDINGS: Acute care use continued to fall over the last decade. The rate of decline increased during the last time period of study and affected seniors to the same degree as younger patients. At the same time, use of extended care decreased, compared to steady increases in earlier years. The result was that by 1995/96 nearly 40 percent of inpatient days were used by people who died in hospital, compared to 9 percent in 1969. These people, however, still represent a small proportion of separations. CONCLUSIONS: The "bed blocker" problem common to many hospital systems appears to have been largely alleviated in British Columbia over the decade 1985-95. The concurrent decrease in extended care use, however, makes it difficult to say where and how these people are now being cared for. Care for the dying has become a bigger issue for hospitals, but whether this is because of heroic interventions at the end of life is not clear. A "top-down," capacity-driven management approach to hospital use in British Columbia has produced effects that may seem familiar to those involved in more "bottom-up" managed care approaches in the United States.

Hospital downsizing and trends in health care use among elderly people in British Columbia.

BACKGROUND: There has been considerable downsizing of acute care services in British Columbia over the past 2 decades. In this population-based study we examined changes in the proportion of elderly people who used acute care, long-term care and home care services between 1986-1988 and 1993-1995 to explore whether the downsizing has influenced use. Changes in death rates were also examined. METHODS: The British Columbia Linked Health Database was used to select all British Columbia residents aged 65 years, 75-76 years, 85-87 years or 90-93 years as of Jan. 1, 1986 (cohort 1), and Jan. 1, 1993 (cohort 2). Each person was assigned to 1 of 6 mutually exclusive categories of health care use reflecting different intensities of use (i.e., hospital, long-term or home care). The proportions of people within each category were compared between the 2 periods, as were the age-standardized death rates. RESULTS: There were 79,175 people in cohort 1 and 92,320 in cohort 2. Overall, the relative proportion of people in each use category was similar between the 2 study periods. The most substantial changes were an increase of 2 percentage points in the proportion of people who received no facility or home care services and a decrease of 2 to 3 percentage points in the proportion who received some acute care but no facility-based continuing care. The age-adjusted all-cause death rates for the earlier and later cohorts were virtually identical (15.7% and 15.8% respectively), although the rate increased from 63.6% to 70.1% among those in the "full-time facility with acute care" group. INTERPRETATION: Overall changes in health care use were small, which suggests that the repercussions of the decline in acute care services for elderly people have been minimal. The higher age-adjusted death rates in the later cohort in full-time care suggests that long-term stays are becoming reserved for a sicker group of elderly people than in the past.

Mortality rates after cataract extraction.

Senile cataract may be a marker of generalized tissue aging. We examined this hypothesis using population-based linked health data. We hypothesized that any such association would diminish with increased use of cataract surgery. Mortality rates of those 50-95 years of age undergoing cataract surgery in British Columbia during either 1985 or 1989 were compared with the provincial population of comparable age who did not undergo cataract surgery during the study period. The 1985 cohort included 8,262 patients undergoing surgery and a comparison population of 804,303, and the 1989 cohort included 11,952 patients and a comparison population of 839,393. Using Cox regression, for the 1985 cohort, the hazard ratios for dying during follow-up were 3.2 for males 50-54.9 years of age [95% confidence limits (CL) = 2.0, 5.0] and 3.3 for females (95% CL = 1.9, 5.7). Hazard ratios for older age groups decreased with age. We also fit an additive risk model that produced excess mortalities that were less age dependent. In the 1985 analysis, these ranged from +7.1 per 1,000 (95% CL = +0.44, +13.76) to +20.3 (95% CL = +13.24, +27.36) for males and -17.5 (95% CL = -28.28, -6.72) to +2.0 (95% CL = -2.12, +6.12) for females. Findings for the 1989 analyses were similar, indicating that the association between cataracts and generalized aging remained constant despite a large increase in the use of cataract surgery.

Effectiveness of community-directed diabetes prevention and control in a rural Aboriginal population in British Columbia, Canada.

This report presents the process and summative evaluation results from a community-based diabetes prevention and control project implemented in response to the increasing prevalence and impact of non-insulin-dependent diabetes mellitus (NIDDM) in the Canadian Aboriginal population. The 24-month project targeted the registered Indian population in British Columbia's rural Okanagan region. A participatory approach was used to plan strategies by which diabetes could be addressed in ways acceptable and meaningful to the intervention community. The strategies emphasised a combination of changing behaviours and changing environments. The project was quasi-experimental. A single intervention community was matched to two comparison communities. Workers in the intervention community conducted interviews of individuals with or at risk for diabetes during a seven-month pre-intervention phase (n = 59). Qualitative analyses were conducted to yield strategies for intervention. Implementation began in the eighth month of the project. Trend measurements of diabetes risk factors were obtained for 'high-risk' cohorts (persons with or at familial risk for NIDDM) (n = 105). Cohorts were tracked over a 16-month intervention phase, with measurements at baseline, the midpoint and completion of the study. Cross-sectional population surveys of diabetes risk factors were conducted at baseline and the end of the intervention phase (n = 295). Surveys of community systems were conducted three times. The project yielded few changes in quantifiable outcomes. Activation of the intervention community was insufficient to enable individual and collective change through dissemination of quality interventions for diabetes prevention and control. Theory and previous research were not sufficiently integrated with information from pre-intervention interviews. Interacting with these limitations were the short planning and intervention phases, just 8 and 16 months, respectively. The level of penetration of the interventions mounted was too limited to be effective. Attention to process is warranted and to the feasibility of achieving effects within 24 months.

Variation by body mass index and age in waist-to-hip ratio associations with glycemic status in an aboriginal population at risk for type 2 diabetes in British Columbia, Canada.

BACKGROUND: It is unclear whether obesity and age modify or confound relations between abdominal adiposity and metabolic risk factors for type 2 diabetes. OBJECTIVE: Our objective was assess the consistency of relations between abdominal adiposity and glycemic variables across discrete categories of obesity and age. DESIGN: We performed a stratified analysis of prevalence data from a rural screening initiative in British Columbia, Canada. Subjects were Salishan Indians, all healthy relatives of individuals with type 2 diabetes [n = 151; age: 18-80 y; body mass index (BMI, in kg/m2): 17.0-48.2]. We measured waist-to-hip ratio (WHR) (2 categories); insulin, glycated hemoglobin (Hb A1c), and 2-h glucose concentrations (2 categories); and BMI (4 categories). BMI and age-specific odds ratios (ORs) and 95% CIs were calculated. RESULTS: WHR-glycemic variable relations were not consistent across BMI and age strata. Risks associated with high WHR were: for persons with BMIs from 25 to 29, elevated insulin (OR: 6.71; 95% CI: 1.41, 34.11) and Hb A1c (OR: 16.23; 95% CI: 2.04, 101.73) concentrations; for persons aged 18-34 y, elevated insulin concentrations [OR: indeterminate (+infinity); 95% CI: 1.89, +infinity]; and, for persons aged 35-49 y, elevated Hb A1c (OR: +infinity; 95% CI: 3.17, +infinity) and 2-h glucose (OR: 9.15; 95% CI: 1.74, 59.91) concentrations. CONCLUSIONS: WHR discriminates risk of type 2 diabetes in overweight but not obese individuals. Abdominal adiposity is associated with elevated insulin concentrations in younger age groups and with impaired glucose control in middle-aged groups, suggesting metabolic staging by age on a continuum from insulin resistance to impaired glucose tolerance.

Creating a population-based linked health database: a new resource for health services research.

As the availability of both health utilization and outcome information becomes increasingly important to health care researchers and policy makers, the ability to link person-specific health data becomes a critical objective. The integration of population-based administrative health databases has been realized in British Columbia by constructing an historical file of all persons registered with the health care system, and by probabilistically linking various program files to this 'coordinating' file. The linkages have achieved a high rate of success in matching service events to person-specific registration records. This success has allowed research projects to be proposed which would otherwise not have been feasible, and has initiated the development of policies and procedures regarding research access to linked data. These policies and procedures include a framework for addressing the ethical issues surrounding data linkage. With continued attention to confidentiality issues, these linked data present a valuable resource for health services research and planning.

Socioeconomic status, mortality, and the development of cataract at a young age.

It has been hypothesized that senile cataract may serve as a marker for generalised tissue aging, since structural changes occurring in the proteins of the lens during cataract formation are similar to those which occur elsewhere as part of the aging process. An earlier analysis we carried out to test this hypothesis revealed a strong age-dependent relationship between undergoing cataract surgery and subsequent mortality. Relative risks for dying over 9 yr of follow-up were particularly increased for individuals who had developed cataract requiring operation between the ages of 50-65. This finding prompted us to test the hypothesis that younger patients undergoing surgery for cataract (those in which surgery was undertaken at 50-65 yr of age) would tend disproportionately to be resident in areas of generally lower socioeconomic status. A population-based linked health data resource containing data on all hospital separations in the province of British Columbia was used to examine this hypothesis. Linkage to Canadian census data was used to assign a socioeconomic decile to the area of residence for all individuals in British Columbia who either did, or did not, undergo cataract surgery over a 3 yr period, and were aged 50-95. Relative to those who resided in the highest socioeconomic areas, odds ratios for undergoing cataract surgery between 50 and 65 yr of age were significantly greater than 1 for the four lowest socioeconomic deciles. This association was observed despite a conservative bias in our setting that favoured those of higher socioeconomic status tending to receive earlier treatment. The results of this ecologic study prompt consideration of whether factors which have the dual attributes of being correlates of socioeconomic status and implicated in the development of cataract may play a role in mediating the processes involved in the well known association of socioeconomic status and mortality.

Paradigm change and uncertainty about funding of public health research: social and scientific implications.

Since the 1970s two fundamental shifts have occurred in health research funding: a reduction in the buying power of research dollars, and an increase in the competition for resources. Most fields have also seen a decrease in the dollars available for research. Pressures for justifying the relevance of research activities have become increasingly pragmatic. The thesis of this paper is that scientific creativity and innovation are compromised by the highly uncertain and competitive funding environment of contemporary health research. This is largely because criteria of scientific excellence predicated on an investigation's presumed future impact support the status quo of methods and subject matter in funded research. Extraordinary rationality among scientists seeking and allocating resources promotes the survival of the existing system over time, yet inhibits progressive development through the transformation of conceptual models. Therefore, despite a growing unrest about the way research on population health is conducted, new conceptions of the relationship between theory and methods have been slow to emerge. Amelioration of a disjunction between the institutionalized rules governing science and the culturally sanctioned goals of science requires commitment to a dialectic between orthodoxy and dissent.

Physicians and breastfeeding: beliefs, knowledge, self-efficacy and counselling practices.

A pilot-tested questionnaire was mailed to 325 obstetricians, pediatricians, family practitioners and general practitioners of a British Columbian maternity hospital to measure aspects relating to physicians' attitudes toward breastfeeding counselling. Response rate was 67.3%. The measures of self-efficacy, knowledge and beliefs were added to a regression model containing measures of gender, specialty, years in practice and personal or spousal breastfeeding experience to determine whether additional variance in counselling behaviour could be accounted for. Physicians attempted to convince women to breastfeed if: 1) they believed in the immune properties of breastmilk (OR = 1.23, SE = 0.07) and 2) they were confident in their own breastfeeding counselling (OR = 1.88, SE = 0.36). Likewise, encouraging women to continue breastfeeding in the face of breastfeeding problems was related to confidence in breastfeeding counselling (OR = 1.22, SE = 0.10) and belief in the immune properties of breastmilk (OR = 2.83, SE = 0.45).

Field trial of the Otago photoscreener.

OBJECTIVE: To assess the effectiveness of the Otago photoscreener in detecting amblyogenic factors in the general population. DESIGN: Prospective clinical trial. SETTING: Suburban school district in Delta, BC. PARTICIPANTS: A total of 1245 kindergarten children. INTERVENTIONS: Screening for visual defects was done with the Otago photoscreener (by a technician) and the regular manual method (by a health care aide). A standard ophthalmologic examination was performed by a pediatric ophthalmologist and an orthoptist in a random sample of 20% of all children with normal results of screening (n = 241) plus all those with abnormal results (n = 29). MAIN OUTCOME MEASURES: Sensitivity, specificity, positive predictive value, rates of false-negative and false-positive results. RESULTS: The Otago screener had higher sensitivity than the manual technique (81% vs. 33%), especially for strabismus and cataracts. The specificity values of the two techniques were 98% and 97% respectively, and the positive predictive values were 77% and 54% respectively. The manual technique failed to identify 5.8% of children with visual defects, compared with 1.6% for the Otago screener. CONCLUSIONS: The Otago photoscreener is a superior instrument for identifying amblyogenic eye disease. However, given the relatively low yield, the value of any screening method should be assessed with regard to both costs and benefits.

Research methods for surgeons: an overview.

The purpose of this paper is to outline a number of salient features in the design and conduct of clinical research in surgery. The key features emphasized are the need for clarity in the elaboration of study hypotheses, clear definition of the variables involved in the study, particularly the outcome variables, the need to confront the issue of bias and confounding, and a review of methodological issues associated with specific components in the research process. Particular attention is paid to patient selection, allocation of patients to experimental and control groups, randomization, problems of co-intervention and contamination, a brief discussion of analytic issues, and the critical importance of getting appropriate design and other methodological assistance prior to initiating a study. A short bibliography providing the reader with more in-depth discussions of the issues raised here is provided. It is the intention of this paper to introduce surgeons undertaking clinical research to these important methodological issues so that they can utilize appropriate consultative services more effectively.

Utilization care plans and effective patient data management.

This article introduces the concept of a utilization care plan (UCP) for supporting the communication of data required for effective utilization review and utilization management. Utilization review is a process of measurement that compares the performance of a ward, department, or entire facility against accepted criteria to identify resource use shortfalls. Utilization management is the deliberate action by third party payers to ensure that shortfalls in resource utilization are minimized. Critical to the success of utilization management is effective data communication; utilization review data must be accurate, complete, accessible, timely, and coordinated. Computer-based UCP systems can remind caregivers when and what services should be provided to patients and also monitor the portion of those services that should be administered during each phase of a patient's therapy. Deviations from the UCP system template constitute variances that can be documented and highlighted in a friendly automated system that ensures highly accurate and extremely timely concurrent utilization information. Some implications of using UCP systems for future research and practice are also discussed.

The psychological consequences of predictive testing for Huntington's disease. Canadian Collaborative Study of Predictive Testing.

BACKGROUND: Advances in molecular genetics have led to the development of tests that can predict the risk of inheriting the genes for several adult-onset diseases. However, the psychological consequences of such testing are not well understood. METHODS: The 135 participants in the Canadian program of genetic testing to predict the risk of Huntington's disease were followed prospectively in three groups according to their test results: the increased-risk group (37 participants), the decreased-risk group (58 participants), and the group with no change in risk (the no-change group) (40 participants). All the participants received counseling before and after testing. Standard measures of psychological distress (the General Severity Index of the Symptom Check List 90-R), depression (the Beck Depression Inventory), and well-being (the General Well-Being Scale) were administered before genetic testing and again at intervals of 7 to 10 days, 6 months, and 12 months after the participants received their test results. RESULTS: At each follow-up assessment, the decreased-risk group had lower scores for distress than before testing (P < 0.001). The increased-risk group showed no significant change from base line on any follow-up measure, but over the year of study there were small linear declines (P < 0.023) for distress and depression. The no-change group had scores lower than at base line on the index of general well-being at each follow-up (P < or = 0.045). At the 12-month follow-up, both the increased-risk group and the decreased-risk group had lower scores for depression and higher scores for well-being than the no-change group (P < or = 0.049). CONCLUSIONS: Predictive testing for Huntington's disease has potential benefits for the psychological health of persons who receive results that indicate either an increase or a decrease in the risk of inheriting the gene for the disease.

Anemia in pediatric day-surgery patients: prevalence and detection.

A prospective study was conducted to determine the prevalence of anemia in pediatric day-surgery patients, and a single-blinded study was conducted to evaluate the anesthesiologist's capability to detect preoperative anemia clinically. The subsequent management of children with anemia was noted. During the preoperative examination the anesthesiologist completed a questionnaire and predicted the preoperative hemoglobin concentration based on the history and physical examination. The preoperative hemoglobin concentration was measured for all of the patients, but the results were withheld until after completion of the questionnaire. Documentation was complete in 2,649 patients, and these comprised the final study group. Fourteen patients (0.5%) were anemic (hemoglobin concentration less than 100 g/l), but of these, only 5 had been predicted to be anemic based on clinical examination. Seven of these 14 anemic patients were less than 1 yr of age. Only 2 of the anemic patients had surgery postponed, and 1 of these also had a respiratory infection. Forty-four patients were incorrectly predicted to be anemic (i.e., their actual hemoglobin concentration was greater than 100 g/l). We conclude that in our patients, anemia is rare but is more likely to occur in those less than 1 yr of age. The presence of mild degrees of anemia does not alter the decision to proceed with day surgery. The anesthesiologists participating in this study could not reliably detect anemia clinically.

Utilization management: a literature review for Canadian health care administrators.

Utilization management (UM), the attempt to measure, understand and reduce inappropriate hospital use, has been in development for over 20 years. It is an outgrowth of two related phenomena: (1) the increasing responsibility of large institutional third party payers for health care costs and the increasing demand of those payers for accountability; and (2) in Canada, particularly, the debate surrounding the adequacy of hospital funding and the perceived inadequacy of cost control using global budgeting. Given the interest in UM, hospital administrators, provincial and federal associations representing hospitals, hospital employees and physicians would find a review of UM programs useful in terms of what is known about their effectiveness, and the specific initiatives in Canada. The authors underscore the critical need for formal evaluation of UM programs; to date there has been little systematic research into issues related to its implementation and impact. This issue is particularly pertinent because UM programs have not been widely implemented in Canada.

Hospital-based utilization management: a cross-Canada survey.

Utilization management attempts to measure, understand and, when appropriate, reduce hospital use. We conducted a telephone survey to determine the status of utilization management in Canadian hospitals. The sample comprised a random selection of 30% of acute-care hospitals with over 100 beds for adults in Ontario and Quebec and all such hospitals in the other provinces. Of the 123 chief executive officers contacted 99 (80%) claimed to have a utilization management program. Of those, 90 (91%) agreed to participate in an in-depth survey or to designate a senior administrator to be interviewed who was most knowledgeable about the program. High occupancy rates and funding issues were the most common environmental triggers for the development of utilization management programs; funding issues were listed more frequently by respondents in Ontario than by those elsewhere (p = 0.0008). Retrospective review alone was used in half of the hospitals, concurrent review or some mixed approach being used in the other half. Ontario and the Atlantic provinces were more reliant than the rest of the country on retrospective review alone (p = 0.0032). Most of the hospitals used peer review and education to stimulate corrective action. Of the respondents 67% indicated that the medical staff supported the utilization management program, and 53% reported that the program had a positive impact on the relationship between administrative and medical staff. Most of the respondents were unsure of the program's impact on the quality of care or the rate of unnecessary hospital admission. However, retrospective review alone was found to be less successful in reducing inappropriate utilization than either concurrent review or combined review (p = 0.0048).