Sociodemographic Characteristics and Mental and Physical Health Diagnoses of Yazidi Refugees Who Survived the Daesh Genocide and Resettled in Canada

Importance

The health status of Yazidi refugees, a group of ethnoreligious minority individuals from northern Iraq who resettled in Canada between 2017 and 2018 after experiencing genocide, displacement, and enslavement by the Islamic State (Daesh), is unknown but important to guide health care and future resettlement planning for Yazidi refugees and other genocide victims. In addition, resettled Yazidi refugees requested documentation of the health impacts of the Daesh genocide.

Objective

To characterize sociodemographic characteristics, mental and physical health conditions, and family separations among Yazidi refugees who resettled in Canada.

Design, Setting, and Participants

This retrospective clinician- and community-engaged cross-sectional study included 242 Yazidi refugees seen at a Canadian refugee clinic between February 24, 2017, and August 24, 2018. Sociodemographic and clinical diagnoses were extracted through review of electronic medical records. Two reviewers independently categorized patients' diagnoses by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and ICD-10-CM chapter groups. Diagnosis frequencies were calculated and stratified by age group and sex. Five expert refugee clinicians used a modified Delphi approach to identify diagnoses likely to be associated with Daesh exposure, then corroborated these findings with Yazidi leader coinvestigators. A total of 12 patients without identified diagnoses during the study period were excluded from the analysis of health conditions. Data were analyzed from September 1, 2019, to November 30, 2022.

Main Outcomes and Measures

Sociodemographic characteristics; exposure to Daesh captivity, torture, or violence (hereinafter, Daesh exposure); mental and physical health diagnoses; and family separations.

Results

Among 242 Yazidi refugees, the median (IQR) age was 19.5 (10.0-30.0) years, and 141 (58.3%) were female. A total of 124 refugees (51.2%) had direct Daesh exposure, and 60 of 63 families (95.2%) experienced family separations after resettlement. Among 230 refugees included in the health conditions analysis, the most common clinical diagnoses were abdominal and pelvic pain (47 patients [20.4%]), iron deficiency (43 patients [18.7%]), anemia (36 patients [15.7%]), and posttraumatic stress disorder (33 patients [14.3%]). Frequently identified ICD-10-CM chapters were symptoms and signs (113 patients [49.1%]), nutritional diseases (86 patients [37.4%]), mental and behavioral disorders (77 patients [33.5%]), and infectious and parasitic diseases (72 patients [31.3%]). Clinicians identified mental health conditions (74 patients [32.2%]), suspected somatoform disorders (111 patients [48.3%]), and sexual and physical violence (26 patients [11.3%]) as likely to be associated with Daesh exposure.

Conclusions and Relevance

In this cross-sectional study, Yazidi refugees who resettled in Canada after surviving the Daesh genocide experienced substantial trauma, complex mental and physical health conditions, and nearly universal family separations. These findings highlight the need for comprehensive health care, community engagement, and family reunification and may inform care for other refugees and genocide victims.

Up-to-date on cancer screening among Ontario patients seen by walk-in clinic physicians: A retrospective cohort study

Walk-in clinics are typically viewed as high-volume locations for managing acute issues but also may serve as a location for primary care, including cancer screening, for patients without a family physician. In this population-based cohort study, we compared breast, cervical and colorectal cancer screening up-to-date status for people living in the Canadian province of Ontario who were formally enrolled to a family physician versus those not enrolled but who had at least one encounter with a walk-in clinic physician in the previous year. Using provincial administrative databases, we created two mutually exclusive groups: i) those who were formally enrolled to a family physician, ii) those who were not enrolled but had at least one visit with a walk-in clinic physician from April 1, 2019 to March 31, 2020. We compared up to date status for three cancer screenings as of April 1, 2020 among screen-eligible people. We found that people who were not enrolled and had seen a walk-in clinic physician in the previous year consistently were less likely to be up to date on cancer screening than Ontarians who were formally enrolled with a family physician (46.1% vs. 67.4% for breast, 45.8% vs. 67.4% for cervical, 49.5% vs. 73.1% for colorectal). They were also more likely to be foreign-born and to live in structurally marginalized neighbourhoods. New methods are needed to enable screening for people who are reliant on walk-in clinics and to address the urgent need in Ontario for more primary care providers who deliver comprehensive, longitudinal care.

Walk-in clinic patient characteristics and utilization patterns in Ontario, Canada: a cross-sectional study

BACKGROUND

Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment.

METHODS

We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits.

RESULTS

Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21).

INTERPRETATION

Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.

A multi-step approach to developing a health system evaluation framework for community-based health care

Background

Community-based health care (CBHC) is a shift towards healthcare integration and community services closer to home. Variation in system approaches harkens the need for a conceptual framework to evaluate outcomes and impacts. We set out to develop a CBHC-specific evaluation framework in the context of a provincial ministry of health planning process in Canada.

Methods

A multi-step approach was used to develop the CBHC evaluation framework. Modified Delphi informed conceptualization and prioritization of indicators. Formative research identified evaluation framework elements (triple aim, global measures, and impact), health system levels (tiers), and potential CBHC indicators (n = 461). Two Delphi rounds were held. Round 1, panelists independently ranked indicators on CBHC relevance and health system tiering. Results were analyzed by coding agreement/disagreement frequency and central tendency measures. Round 2, a consensus meeting was used to discuss disagreement, identify Tier 1 indicators and concepts, and define indicators not relevant to CBHC (Tier 4). Post-Delphi, indicators and concepts were refined, Tier 1 concepts mapped to the evaluation framework, and indicator narratives developed. Three stakeholder consultations (scientific, government, and public/patient communities) were held for endorsement and recommendation.

Results

Round 1 Delphi results showed agreement for 300 and disagreement for 161 indicators. Round 2 consensus resulted in 103 top tier indicators (Tier 1 = 19, Tier 2 = 84), 358 bottom Tier 3 and 4 indicators, non-CBHC measure definitions, and eight Tier 1 indicator concepts—Mortality/Suicide; Quality of Life, and Patient Reported Outcome Measures; Global Patient Reported Experience Measures; Cost of Care, Access to Integrated Primary Care; Avoidable Emergency Department Use; Avoidable Hospitalization; and E-health Penetration. Post Delphi results refined Tier 3 (n = 289) and 4 (n = 69) indicators, and identified 18 Tier 2 and 3 concepts. When mapped to the evaluation framework, Tier 1 concepts showed full coverage across the elements. ‘Indicator narratives’ depicted systemness and integration for evaluating CBHC. Stakeholder consultations affirmed endorsement of the approach and evaluation framework; refined concepts; and provided key considerations to further operationalize and contextualize indicators, and evaluate CBHC as a health system approach.

Conclusions

This research produced a novel evaluation framework to conceptualize and evaluate CBHC initiatives. The evaluation framework revealed the importance of a health system approach for evaluating CBHC.

Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study

Background

Homeless and unstably housed individuals face barriers in accessing healthcare despite experiencing greater health needs than the general population. Case management programs are effectively used to provide care for this population. However, little is known about the experiences of providers, their needs, and the ways they can be supported in their roles. Connect 2 Care (C2C) is a mobile outreach team that provides transitional case management for vulnerable individuals in a major Canadian city. Using an ethnographic approach, we aimed to describe the experiences of C2C team members and explore their perceptions and challenges.

Methods

We conducted participant observations and semi-structured interviews with C2C team members. Data analysis consisted of inductive thematic analysis to identify themes that were iteratively discussed.

Results

From 36 h of field observations with eight team members and 15 semi-structured interviews with 12 team members, we identified five overarching themes: 1) Hiring the right people & onboarding: becoming part of C2C; 2) Working as a team member: from experience to expertise; 3) Proud but unsupported: adding value but undervalued; 4) Team-initiated coping: satisfaction in the face of emotional strain, and; 5) Likes and dislikes: committed to challenges.

Conclusions

A cohesive team of providers with suitable personal and professional characteristics is essential to care for this complex population. Emotional support and inclusion of frontline workers in operational decisions are important considerations for optimal care and program sustainability.

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies

INTRODUCTION

The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures.

METHODS AND ANALYSIS

594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04725630.

PROTOCOL VERSION

Version 1.1; February 2022.

Variation in Patient-Described Barriers to and Facilitators of Diabetes Management by Individual-Level Characteristics: A Cross-Sectional, Open-Ended Survey

This study analyzed patient-described barriers and facilitators related to diabetes management, focusing on how these differ by glycemia and across individual characteristics. A cross-sectional telephone survey was conducted with adult patients with diabetes in Alberta, Canada, asking two open-ended questions to describe the most helpful and difficult components of their diabetes management. Responses were analyzed using directed content analysis using the Theoretical Domains Framework as a template. The most frequently cited facilitator was care context and information, and the most frequently cited barriers were cognitive challenges and structural barriers, with patient-perceived barriers and facilitators varying by individual-level factors.

Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review

Background:

Ongoing primary care during adolescence is recommended by best practice guidelines for adolescents and young adults (AYAs; ages 12-25) with chronic conditions. A synthesis of the evidence on the roles of Primary Care Physicians (PCPs) and benefits of primary care is needed to support existing guidelines.

Methods:

We used Arksey and O’Malley’s scoping review framework, and searched databases (MEDLINE, EMBASE, PsychINFO, CINAHL) for studies that (i) were published in English between 2004 and 2019, (ii) focused on AYAs with a chronic condition(s) who had received specialist pediatric services, and (iii) included relevant findings about PCPs. An extraction tool was developed to organize data items across studies (eg, study design, participant demographics, outcomes).

Results:

Findings from 58 studies were synthesized; 29 (50%) studies focused exclusively on AYAs with chronic health conditions (eg, diabetes, cancer), while 19 (33%) focused exclusively on AYAs with mental health conditions. Roles of PCPs included managing medications, “non-complex” mental health conditions, referrals, and care coordination, etc. Frequency of PCP involvement varied by AYAs; however, female, non-Black, and older AYAs, and those with severe/complex conditions appeared more likely to visit a PCP. Positive outcomes were reported for shared-care models targeting various conditions (eg, cancer, concussion, mental health).

Conclusion:

Our findings drew attention to the importance of effective collaboration among multi-disciplinary specialists, PCPs, and AYAs for overcoming multiple barriers to optimal transitional care. Highlighting the need for further study of the implementation of shared care models to design strategies for care delivery during transitions to adult care.

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

Les défis de la gestion du diabète chez les personnes itinérantes : étude qualitative avec la méthode photovoix

CONTEXTE:

La recherche sur les défis de la prise en charge du diabète chez les personnes itinérantes qui en sont atteintes n’a pas tendance à prendre en considération le point de vue des personnes touchées. Nous avons utilisé une approche de recherche participative avec la communauté pour explorer ces défis.

MÉTHODES:

Nous avons recruté des cochercheurs ayant une connaissance expérientielle de l’itinérance et du diabète. Les chercheurs principaux leur ont offert une formation en recherche et ont préparé le terrain avec eux pour ce projet. Les cochercheurs ont collectivement choisi d’utiliser la méthode photovoix pour illustrer la difficulté de bien s’alimenter quand on est en situation d’itinérance et explorer en quoi cet écueil affecte plus largement la gestion du diabète. Après une formation en photographie et en éthique, les cochercheurs ont pris des photos en lien avec les objectifs du projet et rédigé des récits connexes au moyen de techniques de rédaction inspirée par des photos. Les chercheurs principaux ont analysé les photos et les récits, et ils en ont dégagé des thèmes qui se sont précisés lors de discussions de groupe.

RÉSULTATS:

Les 8 cochercheurs étaient atteints de diabète de type 2 (diagnostiqué de 18 mois à 23 ans auparavant) et avaient vécu en situation d’itinérance pendant des périodes allant de 8 mois à 12 ans. Nous avons dégagé 4 thèmes à partir de 17 photos et récits produits. L’itinérance affecte grandement la santé émotionnelle et mentale des personnes, ce qui nuit à leur capacité de bien gérer leur diabète. Les aliments servis dans les refuges sont rarement nutritifs ou appétissants. L’obtention d’une forme de logement peut faciliter la prise en charge du diabète en créant un environnement stable qui favorise l’autonomie, mais les coûts et le manque de connaissances sont des obstacles à la préparation de repas sains. L’itinérance complique aussi l’accès aux professionnels de la prise en charge du diabète et aux médicaments d’ordonnance.

INTERPRÉTATION:

Les images et les récits associés permettent de dresser un tableau frappant, complet et fidèle des défis auxquels sont confrontées les personnes en situation d’itinérance qui essaient de gérer leur diabète. Comprendre ces défis est la première étape qui permettra aux intervenants et aux décideurs de répondre aux besoins de cette population.

Using concept mapping to prioritize barriers to diabetes care and self-management for those who experience homelessness

BACKGROUND

Diabetes is a chronic medical condition which demands that patients engage in self-management to achieve optimal glycemic control and avoid severe complications. Individuals who have diabetes and are experiencing homelessness are more likely to have chronic hyperglycemia and adverse outcomes. Our objective was to collaborate with individuals experiencing homelessness and care providers to understand the barriers they face in managing diabetes, as a first step in identifying solutions for enhancing diabetes management in this population.

METHODS

We recruited individuals with lived experience of homelessness and diabetes (i.e. clients; n = 32) from Toronto and health and social care providers working in the areas of diabetes and/or homelessness (i.e. providers; n = 96) from across Canada. We used concept mapping, a participatory research method, to engage participants in brainstorming barriers to diabetes management, which were subsequently categorized into clusters, using the Concept Systems Global MAX software, and rated based on their perceived impact on diabetes management. The ratings were standardized for each participant group, and the average cluster ratings for the clients and providers were compared using t-tests.

RESULTS

The brainstorming identified 43 unique barriers to diabetes management. The clients' map featured 9 clusters of barriers: Challenges to getting healthy food, Inadequate income, Navigating services, Not having a place of your own, Relationships with professionals, Diabetes education, Emotional wellbeing, Competing priorities, and Weather-related issues. The providers' map had 7 clusters: Access to healthy food, Dietary choices in the context of homelessness, Limited finances, Lack of stable, private housing, Navigating the health and social sectors, Emotional distress and competing priorities, and Mental health and addictions. The highest-rated clusters were Challenges to getting healthy food (clients) and Mental health and addictions (providers). Challenges to getting healthy food was rated significantly higher by clients (p = 0.01) and Competing priorities was rated significantly higher by providers (p = 0.03).

CONCLUSIONS

Experiencing homelessness poses numerous barriers to managing diabetes, the greatest of which according to clients, is challenges to getting healthy food. This study showed that the way clients and providers perceive these barriers differs considerably, which highlights the importance of including clients' insights when assessing needs and designing effective solutions.

Perspectives on primary care management of obstructive sleep apnea: a qualitative study of patients and health care providers

STUDY OBJECTIVES

Difficulties in providing timely access to care have prompted interest in primary care delivery models for obstructive sleep apnea (OSA). Sustainable implementation of such models requires codesign with input from key stakeholders. The purpose of this study was to identify patient and provider perspectives on barriers and facilitators to optimal, patient-centered management of OSA in a primary care setting.

METHODS

This study was conducted in Alberta, Canada. Data from key stakeholders were collected through an online survey of primary care providers (n = 119), focus groups and interviews with patients living with OSA (n = 28), and workshops with primary care and sleep providers (n = 36). Quantitative survey data were reported using descriptive statistics, and qualitative data were analyzed using an inductive thematic approach.

RESULTS

Several barriers were identified, including poor specialist access, variable primary care providers knowledge of OSA, and lack of clarity about provider roles for OSA management. Barriers contributed to patients being poorly informed about OSA, leading them to separate OSA from their overall health and eroding trust in the system. Suggestions for improvement included integration of care providers in a comprehensive model of care, facilitated by improved system navigation and more effective use of technology. Themes were consistent across data collection methods and between stakeholder groups.

CONCLUSIONS

Although primary care delivery models may improve access to OSA management, stakeholders identified important challenges in the current system. Innovative models of care, developed with input from patients and providers, may mitigate barriers and support optimal primary care management of OSA.

A Subsidized Healthy Food Prescription Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Randomized Controlled Trial

Objectives

It is vital for individuals with type 2 diabetes (T2DM) to adhere to a healthy dietary pattern to maintain optimal blood glucose levels and overall health. Increasing costs of healthy foods, however, are a barrier to maintaining healthful dietary patterns, particularly for individuals with T2DM who are experiencing food insecurity. Poor diet quality may result in difficulties maintaining optimal blood glucose levels, leading to higher rates of diabetes complications, and increased acute care usage and costs. Although the adverse impacts of food insecurity on maintaining optimal blood glucose levels are well documented, effective strategies to this among individuals with T2DM are lacking. One approach is providing subsidies to purchase healthy foods through subsidized healthy food prescription programs. These programs may help reduce food insecurity and improve diet quality, thereby improving blood glucose levels and reducing diabetes complications over time.

Methods

A parallel group randomized controlled trial will examine the effectiveness of a subsidized healthy food prescription program compared to a healthy food prescription alone in improving average blood glucose levels (primary outcome), and other secondary outcomes among 404 adults who are experiencing food insecurity and persistent hyperglycemia. The subsidized healthy food prescription program consists of two core elements: 1) A one-time healthy food prescription pamphlet that outlines an evidence-based healthy dietary pattern; 2) A healthy food subsidy of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. At baseline and 6-month follow-up, participants will provide responses to sociodemographic and health-related items, and a variety of patient-reported outcomes. Biochemical and physical measurements will also be obtained.

Results

The study's theory of change posits that reducing food insecurity and improving diet quality will be key mediators in improving blood glucose levels, which may reduce diabetes complications, and healthcare usage and costs over time.

Conclusions

The results of this study will demonstrate if a subsidized healthy food prescription program results in meaningful changes in average blood glucose levels and other clinically relevant outcomes.

Funding Sources

Alberta Innovates, Alberta Health Services.

Barriers and Facilitators to Using Statins: A Qualitative Study With Patients and Family Physicians

Background

Despite their proven efficacy to reduce cardiovascular disease, statin medication use remains low in individuals at high risk of cardiovascular disease considering their widespread availability and safety. Our objective was to explore the perspectives of patients and family physicians with regard to the barriers and facilitators of statin use in primary care.

Methods

In this qualitative descriptive study, we conducted 2 focus groups with patients (number, n = 8/6) and individual semistructured interviews with family physicians (n = 17) from community settings. Interviewers asked participants about barriers to and facilitators of statin use. Focus groups and interviews were digitally recorded, transcribed, and analyzed in duplicate using conventional content analysis.

Results

Patients were averse to taking statins for a variety of reasons: medication avoidance and burden; inadequate buy-in for statin therapy; and difficulty remembering to take statins regularly. Family physicians perceived similar barriers and reported other barriers: lack of resources such as inadequate tracking systems; specialist-primary care provider guideline discordance; and lack of continuity and relationship. Patients expressed that key facilitators were patient education and support; splitting tablets to increase cost-effectiveness; and changing to a different statin or lower dose in those with side effects. Family physicians described several similar strategies to facilitate therapy as well as shared decision making and clinical decision support tools as enablers for improvement.

Conclusions

We identified several important barriers to and facilitators of statin use at the patient and prescriber level. This information offers insight into strategies to improve statin use and the development of innovative programs and interventions.

Impact of payment model on the behaviour of specialist physicians: A systematic review

Physician payment models are perceived to be an important strategy for improving health, access, quality, and the value of health care. Evidence is predominantly from primary care, and little is known regarding whether specialists respond similarly. We conducted a systematic review to synthesize evidence on the impact of specialist physician payment models across the domains of health care quality; clinical outcomes; utilization, access, and costs; and patient and physician satisfaction. We searched Medline, Embase, and six other databases from their inception through October 2018. Eligible articles addressed specialist physicians, payment models, outcomes of interest, and used an experimental or quasi-experimental design. Of 11,648 studies reviewed for eligibility, 11 articles reporting on seven payment reforms were included. Fee-for-service (FFS) was associated with increased desired utilization and fewer adverse outcomes (in the case of hemodialysis patients) and better access to care (in the case of emergency department services). Replacing FFS with capitation and salary models led to fewer elective surgical procedures (cataracts and tubal ligations) and, with an episode-based model, appeared to increase the use of less costly resources. Four of the seven reforms met their goals but many had unintended consequences. Payment model appears to affect utilization of specialty care, although the association with other outcomes is unclear due to mixed results or lack of evidence. Studies of salary and salary-based reforms point to specialists responding to some incentives differently than theory would predict. Additional research is warranted to improve the evidence driving specialist payment policy.

Innovations in Providing Diabetes Care for Individuals Experiencing Homelessness: An Environmental Scan

OBJECTIVES

For a variety of reasons, homelessness creates major challenges for the management of diabetes, resulting in excess morbidity and mortality in this population. The objective of this study was to document innovations in providing diabetes care for individuals experiencing homelessness.

METHODS

Using directed snowball sampling, we recruited a sample of service providers (family physicians, nurses, social workers, endocrinologists, diabetes educators, shelter workers) in 5 Canadian cities (Vancouver, Calgary, Edmonton, Toronto, Ottawa). Data were collected using detailed, open-ended interviews. Transcripts and field notes were analyzed using thematic analysis.

RESULTS

We interviewed 96 program managers and providers representing 38 organizations. Although many of the same challenges were faced by care providers in different jurisdictions, there was little communication or sharing of experiences across providers and organizations. However, we identified 5 unique and innovative approaches to providing diabetes care to individuals experiencing homelessness. These include: 1) provision of in-shelter care, 2) peer outreach/support workers, 3) diabetes specialty outreach clinics, 4) diabetes group care specific for this population and 5) community-based pharmacy interventions.

CONCLUSIONS

Providers and organizations in different cities face similar challenges in providing diabetes care to individuals who are experiencing homelessness, yet they tend to address these difficulties in isolation. Despite this, numerous organizations have created innovative solutions to improve diabetes care. Sharing experiences across organizations and jurisdictions can facilitate development and implementation of successful program models.

Identification of validated case definitions for medical conditions used in primary care electronic medical record databases: a systematic review

Objectives

Data derived from primary care electronic medical records (EMRs) are being used for research and surveillance. Case definitions are required to identify patients with specific conditions in EMR data with a degree of accuracy. The purpose of this study is to identify and provide a summary of case definitions that have been validated in primary care EMR data.

Materials and Methods

We searched MEDLINE and Embase (from inception to June 2016) to identify studies that describe case definitions for clinical conditions in EMR data and report on the performance metrics of these definitions.

Results

We identified 40 studies reporting on case definitions for 47 unique clinical conditions. The studies used combinations of International Classification of Disease version 9 (ICD-9) codes, Read codes, laboratory values, and medications in their algorithms. The most common validation metric reported was positive predictive value, with inconsistent reporting of sensitivity and specificity.

Discussion

This review describes validated case definitions derived in primary care EMR data, which can be used to understand disease patterns and prevalence among primary care populations. Limitations include incomplete reporting of performance metrics and uncertainty regarding performance of case definitions across different EMR databases and countries.

Conclusion

Our review found a significant number of validated case definitions with good performance for use in primary care EMR data. These could be applied to other EMR databases in similar contexts and may enable better disease surveillance when using clinical EMR data. Consistent reporting across validation studies using EMR data would facilitate comparison across studies.

Systematic review registration

PROSPERO CRD42016040020 (submitted June 8, 2016, and last revised June 14, 2016).

Association of Specialist Physician Payment Model With Visit Frequency, Quality, and Costs of Care for People With Chronic Disease

IMPORTANCE

Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases.

OBJECTIVE

To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109 839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics.

EXPOSURES

Specialist physician payment model (salary-based or FFS).

MAIN OUTCOMES AND MEASURES

Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs.

RESULTS

A total of 90 605 patients received care from FFS physicians and 19 234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31 898 patients (15 949 FFS, 15 949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care-sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13).

CONCLUSIONS AND RELEVANCE

Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases.

A Cost Analysis and Cost-Utility Analysis of a Community Pharmacist-Led Intervention on Reducing Cardiovascular Risk: The Alberta Vascular Risk Reduction Community Pharmacy Project (RxEACH)

BACKGROUND

A randomized trial (the Alberta Vascular Risk Reduction Community Pharmacy Project) showed that a community pharmacist-led intervention was efficacious for reducing cardiovascular (CV) risk. However, the cost of this strategy is unknown.

OBJECTIVES

We examined the short- and long-term cost of a pharmacist-led intervention to reduce CV risk compared to usual care.

METHODS

We conducted a trial-based cost analysis from the perspective of a publicly funded healthcare system. Over 3 and 12 months of follow-up, we examined specific intervention costs (pharmacy claims), related intervention costs (laboratory tests and medications), and ongoing healthcare costs (physician claims, emergency department visits, and hospital admissions). We also used the validated CV Disease Policy Model-Canada to estimate the long-term effects.

RESULTS

A total of 684 participants (mean age 62, 57% male) were included. Overall, there were no significant differences in healthcare costs at 3 or 12 months between the usual care and intervention groups (P = .127). The CV disease-related healthcare cost of managing a patient over a lifetime was estimated to be Can$45 530 (95% uncertainty interval [UI], 45 460-45 580) and Can$40 750 (95% UI, 37 780-43 620) in usual care and intervention groups, respectively, an incremental cost savings of Can$4770 per patient (95% UI, 1900-7760). The intervention dominated usual care (better outcomes and lower costs) across 3-year, 5-year, 10-year, and lifetime horizons.

CONCLUSION

This economic analysis suggests that a clinical pathway-driven pharmacist-led intervention (previously shown to reduce CV risk) was associated with similar measured healthcare costs over 1 year, and lower extrapolated healthcare costs over a patient lifetime. This strategy could be broadly implemented to realize its benefits.

Interventions for improved diabetes control and self-management among those experiencing homelessness: protocol for a mixed methods scoping review

BACKGROUND

Diabetes is a chronic medical condition that requires patients to be actively engaged in intensive self-management to achieve optimal clinical outcomes. Unfortunately, individuals who are experiencing homelessness often struggle to manage diabetes and consequently suffer numerous and severe complications-both acute and chronic. There are many barriers to optimal diabetes self-management among this population, and this may be exacerbated by the lack of tailoring and customization of care to this unique population. Given this disconnect, it is likely that many organizations have attempted to provide specialized innovations for this population-which may or may not be reported in the formal literature. Our objective is to perform a scoping review to summarize and synthesize the experiences of those who have attempted to provide tailored interventions.

METHODS

We propose a mixed methods scoping review that will include both a formal search of the published literature (MEDLINE, CINAHL, EMBASE, Web of Science, Scopus) and a thorough search of the grey literature. Eligible articles and documents are those that report on an intervention or guideline for the management of diabetes among those experiencing homelessness. All titles and abstracts will undergo duplicate review, as will the full article/document. We will include any report that either includes a description of an intervention or provides recommendations for the treatment of individuals who are homeless with diabetes. We will extract both qualitative and quantitative data for analysis and interpretation. Meta-analysis will not be performed.

DISCUSSION

Those experiencing homelessness who also have diabetes often struggle to manage their chronic condition. When care is tailored to suit their needs, it is feasible that outcomes may be improved. By collating and synthesizing information from diverse organizations and jurisdictions, we hope to facilitate the sharing of knowledge with others who wish to provide this type of care.

Past and Future Burden of Inflammatory Bowel Diseases Based on Modeling of Population-Based Data

BACKGROUND & AIMS

Inflammatory bowel diseases (IBDs) exist worldwide, with high prevalence in North America. IBD is complex and costly, and its increasing prevalence places a greater stress on health care systems. We aimed to determine the past current, and future prevalences of IBD in Canada.

METHODS

We performed a retrospective cohort study using population-based health administrative data from Alberta (2002-2015), British Columbia (1997-2014), Manitoba (1990-2013), Nova Scotia (1996-2009), Ontario (1999-2014), Quebec (2001-2008), and Saskatchewan (1998-2016). Autoregressive integrated moving average regression was applied, and prevalence, with 95% prediction intervals (PIs), was forecasted to 2030. Average annual percentage change, with 95% confidence intervals, was assessed with log binomial regression.

RESULTS

In 2018, the prevalence of IBD in Canada was estimated at 725 per 100,000 (95% PI 716-735) and annual average percent change was estimated at 2.86% (95% confidence interval 2.80%-2.92%). The prevalence in 2030 was forecasted to be 981 per 100,000 (95% PI 963-999): 159 per 100,000 (95% PI 133-185) in children, 1118 per 100,000 (95% PI 1069-1168) in adults, and 1370 per 100,000 (95% PI 1312-1429) in the elderly. In 2018, 267,983 Canadians (95% PI 264,579-271,387) were estimated to be living with IBD, which was forecasted to increase to 402,853 (95% PI 395,466-410,240) by 2030.

CONCLUSION

Forecasting prevalence will allow health policy makers to develop policy that is necessary to address the challenges faced by health systems in providing high-quality and cost-effective care.

The association between payment model and specialist physicians' selection of patients with diabetes: a descriptive study

BACKGROUND

As the number of people with chronic diseases increases, understanding the impact of payment model on the types of patients seen by specialists has implications for improving the quality and value of care. We sought to determine if there is an association between specialist physician payment model and the types of patients seen.

METHODS

In this descriptive study, we used administrative data to compare demographic characteristics, illness severity and visit indication of patients with diabetes seen by fee-for-service and salary-based internal medicine and diabetes specialists in Calgary and Edmonton between April 2011 and September 2014. The study cohort included all newly referred adults with diabetes (no appointment with a specialist in prior 4 yr). Diabetes was identified using a validated algorithm that excludes gestational diabetes.

RESULTS

Patients managed by salary-based physicians (n = 2736) were sicker than those managed by fee-for-service physicians (n = 21 218). Patients managed by salary-based specialists were more likely to have 5 or more comorbidities (23.0% [n = 628] v. 18.1% [n = 3843]) and to have been admitted to hospital or seen in an emergency department for an ambulatory care sensitive condition in the year before their index visit, probably reflecting poorer disease control or barriers to optimal outpatient care. A higher proportion of visits to salary-based physicians were for appropriate indications (65.2% [n = 744] v. 55.6% [n = 5553]; risk ratio 1.17, 95% confidence interval 1.09-1.27).

INTERPRETATION

Salary-based specialists were more likely to see patients with a clear indication for a specialist visit, while fee-for-service specialists were more likely to see healthier patients. Future research is needed to determine if the differences in types of patients are attributable to payment model or other provider- or system-level factors.

High-volume general practitioners in Alberta: a descriptive analysis

BACKGROUND

Alberta is considering capping daily fee-for-service physician billings, but little is known about high-volume practice in the province and its impact on patient health outcomes. In this initial study, we conducted a descriptive analysis of general practitioners' patient volumes and billing practices in relation to associated practitioner demographic characteristics.

METHODS

We conducted a retrospective descriptive analysis of the associations of practitioner characteristics, including full-time versus non-full-time practice, provider sex, years in practice, geographic location and international medical graduate status, with high-volume (> 50 visits/d) practice using general practice billing data from 2011 to 2016. Use of general practitioner service codes was described and compared by general practitioner volume status, with adjustment for physician demographic characteristics and geographic parameters.

RESULTS

We included 3465 general practitioners practising fee-for-service in Alberta between 2011 and 2016, of whom 233 (6.7%) were identified as high-volume providers. Physicians who had been in practice longer (odds ratio [OR] 1.04 per year, 95% confidence interval [CI] 1.02-1.05) and international medical graduates (OR 1.89, 95% CI 1.40-2.54) were more likely to exceed 50 patient visits/day. Female physicians were less likely to exceed 50 patient visits/day (OR 0.14, 95% CI 0.07-0.28). Rural practice location was negatively associated with high-volume practice (OR 0.87, 95% CI 0.79-0.95) when we controlled for zone within the province. Zone 5 (North) was associated with high-volume practice (OR 1.95, 95% CI 1.06-3.58). Less than full-time practice was prevalent (1836 providers [53.0%]). High-volume general practitioners billed fewer service codes requiring longer visits, except for the most highly remunerated code (patients with complex health issues).

INTERPRETATION

These results can inform policy-makers when considering payment system changes. Our next step is to examine the association of high-volume practice with outcomes important to patients, such as evidence of treatment failure (emergency department visits and hospital admissions) for conditions sensitive to primary care management.

Patient navigators for people with chronic disease: A systematic review

BACKGROUND

People with chronic diseases experience barriers to managing their diseases and accessing available health services. Patient navigator programs are increasingly being used to help people with chronic diseases navigate and access health services.

OBJECTIVE

The objective of this review was to summarize the evidence for patient navigator programs in people with a broad range of chronic diseases, compared to usual care.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, and Social Work Abstracts from inception to August 23, 2017. We also searched the reference lists of included articles. We included original reports of randomized controlled trials of patient navigator programs compared to usual care for adult and pediatric patients with any one of a defined set of chronic diseases.

RESULTS

From a total of 14,672 abstracts, 67 unique studies fit our inclusion criteria. Of these, 44 were in cancer, 8 in diabetes, 7 in HIV/AIDS, 4 in cardiovascular disease, 2 in chronic kidney disease, 1 in dementia and 1 in patients with more than one condition. Program characteristics varied considerably. Primary outcomes were most commonly process measures, and 45 of 67 studies reported a statistically significant improvement in the primary outcome.

CONCLUSION

Our findings indicate that patient navigator programs improve processes of care, although few studies assessed patient experience, clinical outcomes or costs. The inability to definitively outline successful components remains a key uncertainty in the use of patient navigator programs across chronic diseases. Given the increasing popularity of patient navigators, future studies should use a consistent definition for patient navigation and determine which elements of this intervention are most likely to lead to improved outcomes.

TRIAL REGISTRATION

PROSPERO #CRD42013005857.

Barriers to care in patients with diabetes and poor glycemic control-A cross-sectional survey

AIMS

To determine and quantify the prevalence of patient, provider and system level barriers to achieving diabetes care goals; and to examine whether barriers were different for people with poor glycemic control (HbA1c ≥ 10%; 86 mmol/mol) compared to fair glycemic control (7 to <8%; 53-64 mmol/mol).

METHODS

We administered a survey by telephone to community-dwelling patients with diabetes, to examine patient-reported barriers and facilitators to care. We compared responses in individuals with HbA1c ≥ 10% (86 mmol/mol) against those with HbA1c between 7-8% (53-64 mmol/mol). We examined associations between HbA1c group and barriers to care, adjusting for sociodemographic factors and diabetes duration.

RESULTS

The survey included 805 people with HbA1c ≥ 10% (86 mmol/mol), and 405 people with HbA1c 7-8% (53-64 mmol/mol). Participants with HbA1c ≥ 10% (86 mmol/mol) reported good access to care, however 20% of participants with HbA1c ≥ 10% (86 mmol/mol) felt that their care was not well-coordinated and 9.6% reported having an unmet health care need. In adjusted analysis, patients with HbA1c ≥10% (86 mmol/mol) were more likely to report lack of confidence and inadequate social support, compared to patients with HbA1c 7-8% (53-64 mmol/mol). They were also significantly more likely not to have drug insurance nor to have received recommended treatments because of cost.

CONCLUSIONS

These results reinforce the importance of an individualized, yet multi-faceted approach. Specific attention to financial barriers seems warranted. These findings can inform the development of programs and initiatives to overcome barriers to care, and improve diabetes care and outcomes.

Identification of validated case definitions for chronic disease using electronic medical records: a systematic review protocol

BACKGROUND

Primary care electronic medical record (EMR) data are being used for research, surveillance, and clinical monitoring. To broaden the reach and usability of EMR data, case definitions must be specified to identify and characterize important chronic conditions. The purpose of this study is to identify all case definitions for a set of chronic conditions that have been tested and validated in primary care EMR and EMR-linked data. This work will provide a reference list of case definitions, together with their performance metrics, and will identify gaps where new case definitions are needed.

METHODS

We will consider a set of 40 chronic conditions, previously identified as potentially important for surveillance in a review of multimorbidity measures. We will perform a systematic search of the published literature to identify studies that describe case definitions for clinical conditions in EMR data and report the performance of these definitions. We will stratify our search by studies that use EMR data alone and those that use EMR-linked data. We will compare the performance of different definitions for the same conditions and explore the influence of data source, jurisdiction, and patient population.

DISCUSSION

EMR data from primary care providers can be compiled and used for benefit by the healthcare system. Not only does this work have the potential to further develop disease surveillance and health knowledge, EMR surveillance systems can provide rapid feedback to participating physicians regarding their patients. Existing case definitions will serve as a starting point for the development and validation of new case definitions and will enable better surveillance, research, and practice feedback based on detailed clinical EMR data.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016040020.

The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study

AIMS

People with diabetes and poor glycaemic control are at higher risk of diabetes-related complications and incur higher healthcare costs. An understanding of the sociodemographic and clinical characteristics associated with poor glycaemic control is needed to overcome the barriers to achieving care goals in this population.

METHODS

We used linked administrative and laboratory data to create a provincial cohort of adults with prevalent diabetes, and a measure of HbA_1c that occurred at least 1 year following the date of diagnosis. The primary outcome was poor glycaemic control, defined as at least two consecutive HbA_1c measurements ≥ 86 mmol/mol (10%), not including the index measurement, spanning a minimum of 90 days. We used multivariable Cox proportional hazards models to evaluate the association between baseline sociodemographic and clinical factors and poor glycaemic control.

RESULTS

In this population-based cohort of 169 890 people, younger age was significantly associated with sustained poor glycaemic control, with a hazard ratio (HR) of 3.08, 95% CI (2.79-3.39) for age 18-39 years compared with age ≥ 75 years. Longer duration of diabetes, First Nations status, lower neighbourhood income quintile, history of substance abuse, mood disorder, cardiovascular disease, albuminuria and high LDL cholesterol were also associated with poor glycaemic control.

CONCLUSIONS

Although our results may be limited by the observational nature of the study, the large geographically defined sample size, longitudinal design and robust definition of poor glycaemic control are important strengths. These findings demonstrate the complexity associated with poor glycaemic control and indicate a need for tailored interventions.

Patient navigators for people with chronic disease: protocol for a systematic review and meta-analysis

BACKGROUND

Individuals with chronic diseases may have difficulty optimizing their health and getting the care they need due to a combination of patient, provider, and health system level barriers. Patient navigator programs, in which trained personnel assess and assist patients in overcoming barriers to care, may improve care and outcomes for patients with chronic disease by providing an alternative approach to conventional information and support resources.

METHODS

This systematic review will evaluate the evidence for patient navigator programs, compared to usual care, in patients with chronic disease. We will include RCTs, cluster RCTs, and quasi-randomized RCTs that study the effects of patient navigator programs on clinical outcomes, patient experience, and markers of adherence to care. Studies will be identified by searching MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO, Social Work Abstracts, and the references of included studies. Two authors will screen titles and abstracts independently. Full texts will be reviewed for relevance and data extraction will be done independently by two authors. Studies will be included if they assess patients of any age with one or more chronic diseases. Outcomes will be categorized into groups characterized by their proximity to mechanism of action of the intervention: patient-level outcomes, intermediate outcomes, and process outcomes. Descriptive data about the elements of the patient navigator intervention will also be collected for potential subgroup analyses. Risk of bias will be assessed using the Effective Practice and Organisation of Care Group (EPOC) risk of bias tool. Data will be analyzed using random effects meta-analysis (relative risk for dichotomous data and mean difference for continuous data), if appropriate.

DISCUSSION

A comprehensive review of patient navigator programs, including a summary of the elements of programs that are associated with a successful intervention, does not yet exist. This systematic review will synthesize the evidence of the effect of patient navigator interventions on clinical and patient-oriented outcomes in populations across a comprehensive set of chronic diseases.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005857 .

Perceived barriers to primary care among western Canadians with chronic conditions

BACKGROUND

This analysis explores barriers to the receipt of health care from a primary care physician for management of chronic conditions.

DATA AND METHODS

A population-based survey was administered to adults in Manitoba, Saskatchewan, Alberta and British Columbia who had hypertension, diabetes, heart disease or stroke (n=1,849). Associations between socio-demographic factors and barriers to receipt of primary care were identified.

RESULTS

Most respondents with chronic conditions required care from a primary care physician in the past year and had no difficulty receiving it; about 10% reported a barrier. Barriers were most commonly reported by respondents with diabetes (16%) and were related to initiation of care or waiting too long to get care.

INTERPRETATION

A small percentage of adults with chronic conditions report barriers to receiving care from a primary care physician.

Approach to economic evaluation in primary care: review of a useful tool for primary care reform

OBJECTIVE

To present an overview of the methods of economic evaluation in health care, using examples of studies applicable to primary care.

SOURCES OF INFORMATION

The main concepts discussed in this article were derived from expert opinion and substantiated with well respected textbooks and comprehensive Canadian guidelines. Examples of cost-effectiveness estimates were taken from the published literature.

MAIN MESSAGE

We describe the basic principles of economic evaluation and provide an introduction to its interpretation, using examples of studies applicable to primary care.

CONCLUSION

A basic understanding of health economics will allow primary care practitioners to begin to incorporate economic data, including that from economic evaluations when they are available, into resource planning for their practices.

Health care costs in people with diabetes and their association with glycemic control and kidney function

OBJECTIVE

To determine the association between laboratory-derived measures of glycemic control (HbA1c) and the presence of renal complications (measured by proteinuria and estimated glomerular filtration rate [eGFR]) with the 5-year costs of caring for people with diabetes.

RESEARCH DESIGN AND METHODS

We estimated the cumulative 5-year cost of caring for people with diabetes using a province-wide cohort of adults with diabetes as of 1 May 2004. Costs included physician visits, hospitalizations, ambulatory care (emergency room visits, day surgery, and day medicine), and drug costs for people >65 years of age. Using linked laboratory and administrative clinical and costing data, we determined the association between baseline glycemic control (HbA1c), proteinuria, and kidney function (eGFR) and 5-year costs, controlling for age, socioeconomic status, duration of diabetes, and comorbid illness.

RESULTS

We identified 138,662 adults with diabetes. The mean 5-year cost of diabetes in the overall cohort was $26,978 per patient, excluding drug costs. The mean 5-year cost for the subset of people >65 years of age, including drug costs, was $44,511 (Canadian dollars). Cost increased with worsening kidney function, presence of proteinuria, and suboptimal glycemic control (HbA1c >7.9%). Increasing age, Aboriginal status, socioeconomic status, duration of diabetes, and comorbid illness were also associated with increasing cost.

CONCLUSIONS

The cost of caring for people with diabetes is substantial and is associated with suboptimal glycemic control, abnormal kidney function, and proteinuria. Future studies should assess if improvements in the management of diabetes, assessed with laboratory-derived measurements, result in cost reductions.

Use of outcomes to evaluate surveillance systems for bioterrorist attacks

Background

Syndromic surveillance systems can potentially be used to detect a bioterrorist attack earlier than traditional surveillance, by virtue of their near real-time analysis of relevant data. Receiver operator characteristic (ROC) curve analysis using the area under the curve (AUC) as a comparison metric has been recommended as a practical evaluation tool for syndromic surveillance systems, yet traditional ROC curves do not account for timeliness of detection or subsequent time-dependent health outcomes.

Methods

Using a decision-analytic approach, we predicted outcomes, measured in lives, quality adjusted life years (QALYs), and costs, for a series of simulated bioterrorist attacks. We then evaluated seven detection algorithms applied to syndromic surveillance data using outcomes-weighted ROC curves compared to simple ROC curves and timeliness-weighted ROC curves. We performed sensitivity analyses by varying the model inputs between best and worst case scenarios and by applying different methods of AUC calculation.

Results

The decision analytic model results indicate that if a surveillance system was successful in detecting an attack, and measures were immediately taken to deliver treatment to the population, the lives, QALYs and dollars lost could be reduced considerably. The ROC curve analysis shows that the incorporation of outcomes into the evaluation metric has an important effect on the apparent performance of the surveillance systems. The relative order of performance is also heavily dependent on the choice of AUC calculation method.

Conclusions

This study demonstrates the importance of accounting for mortality, morbidity and costs in the evaluation of syndromic surveillance systems. Incorporating these outcomes into the ROC curve analysis allows for more accurate identification of the optimal method for signaling a possible bioterrorist attack. In addition, the parameters used to construct an ROC curve should be given careful consideration.

Cesarean delivery for twins: a systematic review and meta-analysis

OBJECTIVE

We undertook a systematic review and meta-analysis to determine whether a policy of planned cesarean section or vaginal delivery is better for twins.

STUDY DESIGN

We searched MEDLINE and EMBASE from 1980 through May 2001 using combinations of the following terms: twin, delivery, cesarean section, vaginal birth, birth weight, and gestational age. Studies that compared planned cesarean section to planned vaginal birth for babies weighing at least 1500 g or reaching at least 32 weeks' gestation were included. We computed pooled odds ratios for perinatal or neonatal mortality, low 5-minute Apgar score, neonatal morbidity, and maternal morbidity. The infant was the unit of statistical analysis. Results were considered statistically significant if the 95% CI did not encompass 1.0.

RESULTS

We retrieved 67 articles, 63 of which were excluded. Four studies with a total of 1932 infants were included in the analysis. A low 5-minute Apgar score occurred less frequently in twins delivered by planned cesarean section (odds ratio, 0.47; 95% CI, 0.26-0.88) principally because of a reduction among twins if twin A was in breech position (odds ratio, 0.33; 95% CI, 0.17-0.65). Twins delivered by planned cesarean section spent significantly longer in the hospital (mean difference, 4.01 days; 95% CI, 0.73-7.28 days). There were no significant differences in perinatal or neonatal mortality, neonatal morbidity, or maternal morbidity.

CONCLUSION

Planned cesarean section may decrease the risk of a low 5-minute Apgar score, particularly if twin A is breech. Otherwise, there is no evidence to support planned cesarean section for twins.