Use of hormonal therapy in senior breast cancer patients treated with or without radiotherapy.

PURPOSE: Breast cancer treatment guidelines state that radiotherapy (rt) can reasonably be omitted in selected women 70 years of age and older if they take adjuvant endocrine therapy (aet) for 5 years. We aimed to assess persistence and adherence to aet in women 70 years of age and older, and to examine differences between rt receivers and non-receivers. METHODS: Quebec's medical service and pharmacy claims databases were used to identify seniors undergoing breast-conserving surgery (1998-2005) and initiating aet. Cox proportional hazards models were used to identify predictors of aet non-persistence. RESULTS: Of 3180 women who initiated aet (mean age: 77.5 years), 28% did not receive rt. During the subsequent 5 years, 32% of patients who initiated aet did not persist, 2% filled only a single prescription, and 22% switched medications. Compared with rt receivers, non-receivers discontinued more often (35.5% vs. 30.1%) and earlier (1.4 years vs. 1.6 years). They also became nonadherent earlier (medication possession ratio < 80% at year 3 vs. at year 5). Predictors of nonpersistence included rt omission [hazard ratio (hr): 1.26; 95% confidence interval (ci): 1.09 to 1.46]; age (hr per decade increase: 1.15; 95% ci: 1.01 to 1.31); new medications (hr per medication: 1.01; 95% ci: 1.00 to 1.02); and hospitalizations during aet, (hr per hospitalization: 1.08; 95% ci: 1.05 to 1.11). In a subanalysis of rt non-receivers, significant predictors included hospitalizations (hr: 1.07; 95% ci: 1.02 to 1.12) and medications at aet start (hr: 0.94; 95% ci: 0.91 to 0.97). CONCLUSIONS: Suboptimal use of aet was observed in at least one third of women. In rt non-receivers, aet use was worse than it was in rt receivers. Initiation of new medications and hospitalizations increased the risk of non-persistence.

Factors influencing the quality of local management of ductal carcinoma in situ: a cohort study.

BACKGROUND: Guidelines recommend radiotherapy (rt) after breast-conserving surgery (bcs) for optimal control of ductal carcinoma in situ (dcis). The aim of the present study was to characterize the rates of rt consideration and administration, and to identify factors influencing those rates in a cohort of women diagnosed between 1998 and 2005 in Quebec. METHODS: Quebec's medical service claims and discharge abstract database were used. Using consultation for rt as an indicator for rt consideration, odds ratios (ors) and 95% confidence intervals (cis) were estimated using a generalized estimating equations regression model. RESULTS: Of 4139 women analyzed (mean age: 58 years), 3435 (83%) received a consultation for rt, and 3057 of them (89%) proceeded with treatment. The rate of rt consideration increased by 7.1% over the study period, with notable differences in the various age groups. Relative to women 50-69 years of age, the ors for being considered for rt were, respectively, 0.89 (95% ci: 0.71 to 1.12), 0.71 (95% ci: 0.55 to 0.92), and 0.20 (95% ci: 0.14 to 0.31) for women younger than 50, 70-79, and 80 years of age and older. Distance to a designated breast care centre lowered the probability of rt consideration, but the presence of comorbidities did not. A surgeon's volume of bcss increased the probability of being considered for rt by 7% for every 10 such procedures performed (or: 1.07; 95% ci: 1.04 to 1.11). CONCLUSIONS: Consideration for rt has increased over time. However, older women (despite being in good health) and those living far from a designated breast care centre or having a low-case-volume surgeon were less likely to be considered for rt.

A population-based assessment of systemic lupus erythematosus incidence and prevalence--results and implications of using administrative data for epidemiological studies.

OBJECTIVES: To estimate (i) systemic lupus erythematosus (SLE) incidence and prevalence using multiple sources of population-based administrative data; (ii) the sensitivity and specificity of case ascertainment methods; and (iii) variation in performance of each ascertainment approach, according to patient and physician characteristics. METHODS: We examined the physician billing and hospitalization databases of the province of Quebec (1994-2003) covering all health care beneficiaries (approximately 7.5 million). We compared various approaches to ascertain SLE cases, using information from each database separately or combining sources; we then estimated the sensitivity and specificity of these alternative approaches. We used regression models to determine if sensitivity was independently influenced by patient or physician characteristics. RESULTS: Using billing data, we calculated SLE incidence at 3.0/100,000 person-years [95% confidence interval (CI) 2.6-3.4]; prevalence was 32.8/100,000 persons, in 2003. Results were similar using hospitalization data. However, only a proportion of prevalent cases were identified as having SLE by both methods. Combining cases from billing and hospitalization data, we found a prevalence of 51/100,000 in 2003. Our latent class regression model estimated a prevalence of 44.7/100,000 (95% CI 37.4-54.7). We found high specificity for SLE diagnoses across all strategies and data sources; sensitivity ranged from 42.1% to 67.6%, and was independently influenced by both patient and physician characteristics. CONCLUSIONS: In observational studies, particularly with administrative databases, SLE incidence and prevalence estimates differ considerably, according to the approach for case ascertainment. In the absence of gold standards, statistical modelling can provide sensitivity and specificity estimates for different approaches.

Evaluation of standardized tasks for primary care physicians using the MOXXI electronic prescribing and integrated drug management system.

The Medical Office for the Twenty First Century (MOXXI) is a research project testing the potential benefits of an electronic prescription and drug management system for primary care physicians. This system includes a dynamic electronic pad for prescription entry with fields for treatment indications; a drug profiler with a graphic representation of the list of prescription medications purchased in the last year; a refill compliance calculator; dates of emergency room visits and hospital admissions; cost of drugs dispensed; and an alert system that detects interactions among drugs, treatment duplications, and contraindications with certain allergies or specific diseases. One concern expressed by physicians that could influence uptake and acceptability is the increased time that may be required to use the system. User abilities are a factor in this process, as well as user interface, user training and system speed.

The impact of pharmacotherapy policy: a case study.

Universal drug insurance coverage has been endorsed by the National Health Forum and the Liberal government as a means of providing equitable access to prescription medication for Canadians. In 1996, Quebec legislated a universal drug insurance program. To finance extended coverage for approximately 1.2 million previously uninsured beneficiaries, an income-indexed coinsurance and deductible cost-sharing policy was introduced for previously insured beneficiaries (people 65 years of age and older, and those receiving income security allowance). The increase in cost-sharing for previously insured beneficiaries led to a reduction in both essential (senior citizens: 9.1%; income security: 14.4%) and less essential medication (senior citizens: 15.1%; income security: 22.4%). Reductions in the use of essential drugs were associated with an increase in the rate of emergency visits (by 43% in senior citizens and 78% in income security recipients) and adverse events (by over 100% in senior citizens and 88% in income security recipients). The 442 physicians and pharmacists who were surveyed reported that the policy reduced the use of antilipidemics, inhaled steroids and antihypertensives in the previously insured beneficiaries, but improved access to previously unaffordable medications for cardiac disease and asthma in the newly insured beneficiaries. Although universal drug insurance appeared to enhance access to essential medication for the newly insured, these benefits were exacted at a cost of producing unintended health effects in two vulnerable subgroups: senior citizens and income security recipients. Because no prior studies have shown that consumer cost sharing can lead to expected objective of selective reductions in less essential drug use alone, alternate policy approaches for financing universal drug coverage need to be considered.

Identification of persons with cardiorespiratory conditions who are at risk of dying from the acute effects of ambient air particles.

This study was undertaken to identify subgroups of the population susceptible to the effects of ambient air particles. Fixed-site air pollution monitors in Montreal, Quebec, Canada, provided daily mean levels of various measures of particulates and gaseous pollutants. Total sulfates were also measured daily (1986-1993) at a monitoring station 150 km southeast of the city (Sutton, Quebec, Canada). We used coefficient of haze (COH), extinction coefficient, and Sutton sulfates to predict fine particles and sulfates from a fine particles model for days that were missing. We used the universal Quebec medicare system to obtain billings and prescriptions for each Montreal resident who died in the city from 1984 to 1993. These data were then used to define cardiovascular and respiratory conditions that subjects had before death. Using standard Poisson regression time-series analyses, we estimated the association between daily nonaccidental mortality and daily concentrations of particles in the ambient air among persons with cardiovascular and respiratory conditions diagnosed before death. We found no persuasive evidence that daily mortality increased when ambient air particles were elevated for subgroups of persons with chronic upper respiratory diseases, airways disease, cerebrovascular diseases, acute coronary artery disease, and hypertension. However, we found that daily mortality increased linearly as concentrations of particles increased for persons who had acute lower respiratory diseases, chronic coronary artery diseases (especially in the elderly), and congestive heart failure. For this latter set of conditions, the mean percent increase in daily mortality (MPC) for an increase in the COH across its interquartile range (18.5 COH units per 327.8 linear meters), averaged over the day of death and the 2 preceding days, was MPC = 5.09% [95% confidence interval (CI) 2.47-7.79%], MPC = 2.62 (95% CI 0.53-4.75%), and MPC = 4.99 (95% CI 2.44-7.60%), respectively. Adjustments for gaseous pollutants generally attenuated these associations, although the general pattern of increased daily mortality remained. In addition, there appeared to be a stronger association in the summer season. The positive associations found for persons who had acute lower respiratory diseases and congestive heart failure are consistent with some prevailing hypotheses and may also be consistent with recent toxicologic data implicating endothelins. Further epidemiologic studies are required to confirm these findings.

The association between daily mortality and ambient air particle pollution in Montreal, Quebec. 1. Nonaccidental mortality.

This study was undertaken to determine whether variations in concentrations of particles in the ambient air of Montreal, Quebec, during the period 1984 to 1993, were associated with daily variations in nonaccidental mortality. Fixed-site air pollution monitors in Montreal provided daily mean levels of various measures of particulates and gaseous pollutants. Total sulfates were also measured daily (1986-1993) at a monitoring station 150 km southeast of the city (Sutton, Quebec). We estimated associations for PM(2.5), PM(10), total suspended particles, coefficient of haze (COH), extinction coefficient, and sulfates. We used coefficient of haze, extinction coefficient, and Sutton sulfates to predict fine particles and sulfates for days that were missing. To estimate the associations between nonaccidental mortality and ambient air particles, we regressed the logarithm of daily counts of nonaccidental mortality on the daily mean levels for the above measures of particulates, after accounting for seasonal and subseasonal fluctuations in the mortality time series, non-Poisson dispersion, weather variables, and gaseous pollutants. There were 140,939 residents of Montreal who died during the study period. We found evidence of associations between daily nonaccidental deaths and most measures of particulate air pollution. For example, the mean percentage increase (MPC) for an increase of total suspended particles of 28.57 microg/m(3) (interquartile range, IQ), evaluated at lag 0 days, was 1.86% (95% confidence interval (CI): 0.00-3.76%), and for an increase of coefficient of haze (IQ=18.5 COH units per 327.8 linear m) the MPC was 1.44% (95% CI: 0.75-2.14%). These results are similar to findings from other studies (the mean percentage increase in nonaccidental deaths for a 100 microg/m(3) increase in daily total suspended particles was 6.7%). We also found increases for fine particles and for inhalable particles, but the confidence intervals included unity. All measures of sulfates showed increased daily mortality; e.g., the MPC for sulfates from fine particles (IQ=3.51 microg/m(3)) was 1.86% (95% CI: 0.40-3.35%). We generally found higher excesses in daily mortality for persons 65 years of age and for exposures averaged across lags 0, 1, and 2 days. The slope of the association between daily mortality and ambient air particles in Montreal, which has lower levels of pollution than most major urban centers, is similar to that reported in most other industrialized cities. This study therefore provides further evidence that the association is linear and that any threshold effect, should it exist, would be found at lower levels of air pollution than those found in Montreal.

The association between daily mortality and ambient air particle pollution in Montreal, Quebec. 2. Cause-specific mortality.

This study was undertaken to determine whether variations in concentrations of particulates in the ambient air of Montreal, Quebec, during the period 1984 to 1993, were associated with daily variations in cause-specific daily mortality. Fixed-site air pollution monitors in Montreal provided daily mean levels of various measures of particles and gaseous pollutants. Total sulfate was also measured daily (1986-1993) at a monitoring station 150 km southeast of the city (Sutton, Quebec). We used coefficient of haze (COH), extinction coefficient, and sulfate from the Sutton station to predict fine particles and sulfate from fine particles for days that were missing. We estimated associations between cause-specific mortality and PM(2.5), PM(10), predicted fine particles and fine sulfate particles, total suspended particles, coefficient of haze, extinction coefficient, and total sulfate measured at the Sutton station. We selected a set of underlying causes of death, as recorded on the death certificates, as the endpoint and then regressed the logarithm of daily counts of cause-specific mortality on the daily mean levels for the above measures of particulates, after accounting for seasonal and subseasonal fluctuations in the mortality time series, non-Poisson dispersion, weather variables, and gaseous pollutants. We found positive and statistically significant associations between the daily measures of ambient particle mass and sulfate mass and the deaths from respiratory diseases and diabetes. The mean percentage change in daily mortality (MPC), evaluated at the interquartile range for pollutants averaged over the day of death and the preceding 2 days, for deaths from respiratory diseases was MPC(COH)=6.90% (95% CI: 3.69-10.21%), MPC(Predicted PM2.5)= 9.03% (95% CI: 5.83- 12.33%), and MPC(Sutton sulfate)=4.64% (95% CI: 2.46-6.86%). For diabetes, the corresponding estimates were MPC(COH)=7.50% (95% CI: 1.96-13.34%), MPC(Predicted PM2.5)=7.59% (95% CI: 2.36-13.09%), and MPC(Sutton sulfate)=4.48% (95% CI: 1.08-7.99%). Among individuals older than 65 years at time of death, we found consistent associations across our metrics of particles for neoplasms and coronary artery diseases. Associations with sulfate mass were also found among elderly persons who died of cardiovascular diseases and of lung cancer. These associations were consistent with linear relationships. The associations found for respiratory diseases and for cardiovascular diseases, especially in the elderly, are in line with some of the current hypotheses regarding mechanisms by which ambient particles may increase daily mortality. The positive associations found for cancer and for diabetes may be understood through a general hypothesis proposed by Frank and Tankersley, who suggested that persons in failing health may be at higher risk for external insults through the failure of regulating physiological set points. The association with diabetes may be interpreted in light of recent toxicological findings that inhalation of urban particles in animals increases blood pressure and plasmatic levels of endothelins that enhance vasoconstriction and alter electrophysiology. Further research to confirm these findings and to determine whether they are causal is warranted.

Adverse events associated with prescription drug cost-sharing among poor and elderly persons.

CONTEXT: Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups. OBJECTIVES: To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation. DESIGN AND SETTING: Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events. PARTICIPANTS: A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients. MAIN OUTCOME MEASURES: Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction. RESULTS: After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits. CONCLUSIONS: In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.

There's no place like home : an evaluation of early supported discharge for stroke.

BACKGROUND AND PURPOSE: Because stroke management is aimed at facilitating community reintegration, it would be logical that the sooner the patient can be discharged home, the sooner reintegration can commence. The purpose of this study was to determine the effectiveness of prompt discharge combined with home rehabilitation on function, community reintegration, and health-related quality of life during the first 3 months after stroke. METHODS: A randomized trial was carried out involving patients who required rehabilitation services and who had a caregiver at home. When medically ready for discharge, persons with stroke were randomized to either the home intervention group (n=58) or the usual care group (n=56). The home group received a 4-week, tailor-made home program of rehabilitation and nursing services; persons randomized to the usual care group received services provided through a variety of mechanisms, depending on institutional, care provider, and personal preference. The main outcome measure was the Physical Health component of the Measuring Outcomes Study Short-Form-36 (SF-36). Associated outcomes measures included the Timed Up & Go (TUG), Barthel Index (BI), the Older Americans Resource Scale for instrumental activities of daily living (OARS-IADL), Reintegration to Normal Living (RNL), and the SF-36 Mental Health component. RESULTS: The total length of stay for the home group was, on average, 10 days, 6 days shorter than that for the usual care group. There were no differences between the 2 groups on the BI or on the TUG at either 1 or 3 months after stroke; however, there was a significantly beneficial impact of the home intervention on IADL and reintegration (RNL). By 3 months after stroke, the home intervention group showed a significantly higher score on the SF-36 Physical Health component than the usual care group. The total number of services received by the home group was actually lower than that received by the usual care group. CONCLUSIONS: Prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community reintegration, and these in turn were translated into a better physical health.

Using medical services claims to assess injuries in the elderly: sensitivity of diagnostic and procedure codes for injury ascertainment.

The sensitivity of using physician claims data for injury ascertainment was examined in a cohort of 1,181 elderly who were treated in the emergency department of one of 10 hospitals for injuries in 1993-1994. The clinical record of the type and date of injury was compared with diagnostic and procedure codes in the Quebec health insurance agency records of physician billing claims for the same patients. The proportion of patients correctly classified by claims data was determined for the exact date of injury and for a time window around the date of injury. The most common injuries were fractures (55.4%) and lacerations (19.3%), and 78.9% of injuries were fall related. Overall, the combination of treatment procedure codes and diagnostic codes provided the most sensitive measure of injury occurrence; a sensitivity of 67.3% for the exact date and 81.3% for an expanded data window (95.6% of injuries were within -1 day to +3 days of the injury date). Sensitivity varied by injury type form a low of 14% for abrasions to a high of 97.2% for hip fractures. The combination of diagnostic and procedure codes in physician claims is a sensitive indicator of some common injuries that would not be documented in hospitalization databases.

Identifying subgroups of the general population that may be susceptible to short-term increases in particulate air pollution: a time-series study in Montreal, Quebec.

This study was undertaken in order to shed light on which groups of the general population may be susceptible to the effects of ambient particles. The objectives of the study were (1) to determine whether concentrations of particles in the ambient air of Montreal, Quebec, were associated with daily all-cause and cause-specific mortality in the period 1984 to 1993, and (2) to determine whether groups of the population had higher than average risks of death from exposure to particles. From the network of fixed-site air pollution monitors in Montreal we obtained daily mean levels of various measures of particles, gaseous pollutants, and weather variables measured at Dorval International Airport. We also used measurements of sulfate from an acid rain monitoring station 150 km southeast of the city (Sutton, Quebec). We estimated associations for particulate matter (PM) with an aerodynamic diameter of 10 microns or smaller (PM10), or 2.5 microns or smaller (PM2.5), total suspended particles (TSP), coefficient of haze (COH), an extinction coefficient, and sulfate. Because substantial data for fine particles were missing, we developed a regression model to predict PM2.5 and to predict sulfate from PM2.5. In the main body of the report, we present results for COH, predicted PM2.5, and sulfate. Detailed results for all pollutants are included in Appendices H through O, which are available on request from Health Effects Institute and from the HEI web site at www.healtheffects.org. To address the first objective, we made use of the underlying causes of death among all 140,939 residents of Montreal who died between 1984 and 1993. We regressed the logarithm of daily counts of cause-specific mortality on the daily mean levels for a variety of measures of particles, accounting for seasonal and subseasonal fluctuations in the mortality time series, overdispersion, and weather factors. To address the second objective, we developed algorithms to define conditions that subjects had prior to death, with the focus on cardiopulmonary diseases. These algorithms were based on information retained on the databases of the universal Quebec Health Insurance Plan (QHIP). The databases include records of all procedures (e.g., type of surgery), physician visits, and consultations carried out by all physicians in Quebec. For persons > or = 65 years and for all recipients of social assistance the prescription database contains records of all pharmaceuticals dispensed (type of medication, dose, quantity). For each group of conditions defined, we used the same statistical model that was used in the analyses of all nonaccidental causes of death. In the analyses of cause-specific mortality, we found evidence of associations for all nonaccidental causes of death and specific causes of death--cancer, coronary artery disease, respiratory diseases, and diabetes--that were consistent across most metrics of ambient air particle concentrations, evaluated as the 3-day mean of particle concentrations measured on the day of death (lag 0) and on each of the two days before death (lag 1, lag 2). Associations for all cardiovascular diseases combined were found only with sulfate. As well, we generally found increased daily mortality for persons 65 years of age and over. The results for all nonaccidental causes of death are similar to findings from other studies; the mean percent increase in mortality for a 100 micrograms/m3 increase in daily TSP at lag 0 was 6.7%. In the analyses of the groups defined from the QHIP data, there was little evidence of associations with air pollutants among persons who before death were classified as having acute or chronic upper respiratory diseases, airways diseases, hypertension, acute coronary artery diseases, and cerebrovascular diseases. On the other hand, we found consistent increases across most types of ambient particles for persons who had cancer, acute lower respiratory diseases, any form of cardiovascular disease, chronic coronary artery diseases, and congestive heart failure. As well, we found an association for individuals who did not have any cardiovascular disease, lower respiratory diseases, and cancer. This latter group consisted of persons who had no interactions with the health care system one year before death (12%) and individuals with a wide variety of potentially fatal diseases (52%), including neurological conditions (12%), diabetes (8%), cardiac dysrhythmias (8%), dementia (6%), organic psychotic disorders (6%), and anemias (4%). As statistical power was reduced in the analyses presented above, differences between groups (e.g., < 65 and > or = 65 year age groups) were not usually statistically significant. The association with diabetes has not been reported previously, and this needs to be replicated in other studies. (ABSTRACT TRUNCATED)

Coding accuracy of hospital discharge data for elderly survivors of myocardial infarction.

OBJECTIVE: To assess the coding accuracy of primary and secondary discharge diagnoses in the Quebec hospital discharge database for elderly persons with myocardial infarction (MI). DESIGN: Retrospective chart review in a convenience sample of six Montreal hospitals. The diagnoses listed in the medical chart were compared with those listed in the hospital discharge database. For each subject, the Charlson comorbidity index was calculated twice, once based on the medical chart and again based on the hospital discharge database. PATIENTS: Subjects aged 65 years and over who had an MI coded as the primary discharge diagnosis in the hospital discharge database and who were discharged alive. MAIN RESULTS: For 234 MI survivors, the positive predictive value (ie, probability that a patient with MI reported in the hospital discharge database had an MI diagnosed by the discharging physician) for coding MI was 0.96 (95% CI 0.94, 0.98). Comorbid medical conditions and complications of the MI were under-reported in the hospital discharge database, which meant that the Charlson index based on the hospital discharge database was an average of 0.71 units lower than the Charlson index based on the medical chart. CONCLUSIONS: When studying survivors of MI by using hospital discharge databases, the advantages must be weighed against potential drawbacks in the quality of the information. Hospital discharge databases are almost as reliable as medical charts for identifying MI patients, but there is substantial under-reporting of comorbid medical conditions.

Screening mammography referral rates for women ages 50 to 69 years by recently-licensed family physicians: physician and practice environment correlates.

BACKGROUND: Physician mammography referral remains below optimal levels despite a long-standing recommendation that all women ages 50 to 69 years receive screening mammography every 1 to 2 years. The purpose of this study was to determine physician and practice environment predictors of family physicians' screening mammography referral rates to women ages 50-69 years. METHOD: A cohort of 498 recently-licensed family physicians was followed for 18-months of incipient medical practice. The referral rate was the percentage of new clinically eligible women patients seen in a primary care context who had a screening mammogram ordered by the study physician. Mammograms and independent variables were identified from physician claims to a Canadian universal health insurance agency. The effects of factors in a conceptual framework were assessed using multivariable linear regression. RESULTS: Correlates of higher mammography referral rates were female gender, better general prevention knowledge, the combination of comprehensive inquiry and continuity care, lower patient volume, and lower shared primary care (multivariable model R(2) = 0.47). Factors belonging to practice environment explained more of the observed variance than did physician characteristics. CONCLUSIONS: Mammography referral varies enormously and almost half of the variance is explained by physician characteristics and practice preferences. Higher mammography referral is observed in practices with more comprehensive and continuity care.

Survival after percutaneous endoscopic gastrostomy among older residents of Quebec.

CONTEXT: Percutaneous endoscopic gastrostomy has become a mainstay of nutritional support for individuals with swallowing dysfunction. There is little population-based data to guide the use of this intervention in older individuals. OBJECTIVE: To describe the use of percutaneous endoscopic gastrostomy among older residents of Quebec and to evaluate patient characteristics associated with subsequent survival and hospital discharge. DESIGN: A population-based cohort study. SETTING: Quebec, Canada. PATIENTS: 175 individuals with a billing claim for percutaneous endoscopic gastrostomy performed in 1993. MEASUREMENTS: Billing and hospitalization databases were used to collect patient characteristics, medical diagnoses, discharge destinations, and dates of death. The relationships between demographic and diagnostic variables before gastrostomy, and subsequent survival and discharge home, were evaluated using survival analysis. RESULTS: Median survival after gastrostomy was 210 days. Mortality at 30 days was 18.3%. Decreased survival was associated with a previous diagnosis of malignancy (risk ratio (RR) = 1.71; 95% CI, 1.09-2.68); mortality did not increase with increasing age. Of 163 individuals hospitalized at the time of gastrostomy, 42 (26%) were discharged home. Individuals with a previous diagnosis of stroke (RR = 2.80; 95% CI 1.01-7.77) were more likely to be discharged home than other individuals. CONCLUSIONS: Survival after percutaneous endoscopic gastrostomy is poor; the requirement for such a procedure appears to be a marker for severe underlying disease. The greater likelihood of return home after gastrostomy among individuals with stroke suggests that the use of this intervention as an adjunct to rehabilitation is appropriate in these individuals.

Risk of a new benzodiazepine prescription in relation to recent hospitalization.

OBJECTIVE: To determine if recent hospital admission was associated with new outpatient prescribing of benzodiazepines among community-dwelling older people. DESIGN: Nested case-control study using administrative data sets of the provincial health insurance board. SETTING: Province of Quebec. PARTICIPANTS: Cases were 4127 community-dwelling older people who were newly dispensed a benzodiazepine during an 8-month period in 1990. Controls were 16,486 community-dwelling older people who were dispensed any drug (except a benzodiazepine) on the same day as the case-defining index prescription. EXPOSURE AND OUTCOME MEASURES: Admission to an acute care hospital within a 30-day period before a new dispensing of a benzodiazepine. Other variables measured were patient age, gender, number of ambulatory physician visits, healthcare region, Chronic Disease Score (CDS), and use of drugs for depression and psychosis. RESULTS: Cases were more than three times as likely as controls to have been hospitalized in the 30-day period before the index date (adjusted odds ratio (OR) 3.09; 95% CI, 2.78-3.45). The use of prescription drugs for physical health problems modified this association in that cases who used more medication were also more likely to receive a new benzodiazepine prescription following a recent hospital admission (adjusted OR 4.09; 95% CI, 3.59-4.65 when the CDS was equal to 5 vs adjusted OR 1.96; 95% CI, 1.66-2.31 when the CDS was equal to 0). CONCLUSIONS: Recent hospitalization confers an increased risk of a new outpatient benzodiazepine prescription among community-dwelling older people in Quebec. Those who use more medication, and who may be more vulnerable to drug-related adverse events, are more likely to be newly dispensed a benzodiazepine following a recent, acute-care hospital admission.

Association between licensing examination scores and resource use and quality of care in primary care practice.

CONTEXT: Clinical competence is a determinant of the quality of care delivered, and may be associated with use of health care resources by primary care physicians. Clinical competence is assumed to be assessed by licensing examinations, yet there is a paucity of information on whether scores achieved predict subsequent practice. OBJECTIVE: To determine if licensing examination scores were associated with selected aspects of quality of care and resource use in initial primary care practice. DESIGN: Prospective cohort study of recently licensed family physicians, followed up for the first 18 months of practice. SETTING: The Quebec health care system. PARTICIPANTS: A total of 614 family physicians who passed the licensing examination between 1991 and 1993 and entered fee-for-service practice in Quebec. MAIN OUTCOME MEASURES: All patients seen by physicians were identified by the universal health insurance board and all health services provided to these patients were retrieved for the 18 months prior to (baseline) and after (follow-up) the physicians' entry into practice. Medical service and prescription claims files were used to measure rates of resource use (specialty consultation, symptom-relief prescribing compared with disease-specific prescribing) and quality of care (inappropriate prescribing, mammography screening). Baseline data were used to adjust for differences in practice population. RESULTS: Study physicians saw a total of 1116389 patients, of whom 113535 (10.2%) were elderly and 83391 (7.5%) were women aged 50 to 69 years. Physicians with higher licensing examination scores referred more of their patients for consultation (3.8/1000 patients per SD increase in score; 95% confidence interval [CI], 1.2-7.0; P = .005), prescribed to elderly patients fewer inappropriate medications (-2.7/1000 patients per SD increase in score; 95% CI, -4.8 to -0.7; P=.009) and more disease-specific medications relative to symptom-relief medications (3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P= .03), and referred more women aged 50 to 69 years (6.6/1000 patients per SD increase in score; 95% CI, 1.2-11.9; P = .02) for mammography screening. If patients of physicians with the lowest scores had experienced the same rates of consultation, prescribing, and screening as patients of physicians with the highest scores, an additional 3027 patients would have been referred, 179 fewer elderly patients would have been prescribed symptom-relief medication, 912 more elderly patients would have been prescribed disease-specific medication, 189 fewer patients would have received inappropriate medication, and 121 more women would have received mammography screening. CONCLUSIONS: Licensing examination scores are significant predictors of consultation, prescribing, and mammography screening rates in initial primary care practice.

Normal distributions of thermal and vibration sensory thresholds.

The distributions of sensory thresholds were estimated in a healthy population while controlling for potential covariates. Using the method of levels and the two-alternative forced choice, thermal and vibration thresholds respectively were measured in the hand and foot of 148 subjects. Age was uniformly distributed between 20 and 86 years. Independent effects of age, gender, height, and skin temperature were estimated using multiple linear regression. Parametric and nonparametric methods were used to estimate the distributions of interest. Significant age-related increases were observed for all vibration thresholds (P < 0.0001), and for thermal thresholds in the foot (P < 0.0002). Percentiles were estimated for thermal thresholds in the hand and age-adjusted continuous distributions were calculated for all other thresholds. Height was positively associated with vibration thresholds in the foot (P < 0.003), and appropriate corrections were made. Our results provide reference values for thermal and vibration sensory thresholds in a healthy population, allowing for the accurate diagnosis of disordered sensory function.

Use of standardized patients to assess between-physician variations in resource utilization.

CONTEXT: As medical costs are increasingly being scrutinized, there is heightened interest in defining variations in physician behavior in clinical settings. OBJECTIVE: To evaluate if standardized patient (SP) technology is a reliable and feasible method of studying interphysician variations in test ordering, referral requests, prescribing behavior, and visit costs. DESIGN: The study was conducted with blinded SP visits to family medicine and internal medicine residents, university-affiliated family physicians, and community-based family physicians. Resource utilization and visit costs were assessed using test requisitions, consult requests, and prescriptions that were collected by the SPs. SETTING: Physicians' offices in ambulatory care, hospital-based clinics and in the community. PARTICIPANTS: Four persons (aged 57-77 years) trained to simulate having osteoarthritis of the hip. In one simulation, the patient had gastropathy due to nonsteroidal anti-inflammatory drug use, and in the other, the patient sought therapy for hip discomfort. MAIN OUTCOME MEASURES: Reliability of cost estimates of physician services, tests, consultations, prescriptions, and total visits and test-ordering behavior for nonsteroidal anti-inflammatory gastropathy. RESULTS: Overall, 112 (63%) of the physicians who were sent invitations to the study agreed to participate. Of 312 total SP visits conducted over a 1-year period, unblinding due to SP detection occurred on 36 occasions (11.5%). Reliable cost estimates of physician services, tests, and consultations, and moderately reliable estimates of total visit costs, were obtained with 4 visits per practicing physician and with 2 visits per resident. There were extreme variations in total visit costs generated by the study physicians. A small number of physicians had a major impact on this variability. CONCLUSION: Standardized patient technology provides a reliable, feasible method to assess variations in resource utilization between physicians.