Effects of a Province-wide Triaging System for TIA: The ASPIRE Intervention

BACKGROUND AND OBJECTIVES

Urgent transient ischemic attack (TIA) management to reduce stroke recurrence is challenging, particularly in rural and remote areas. In Alberta, Canada, despite an organized stroke system, data from 1999 to 2000 suggested that stroke recurrence after TIA was as high as 9.5% at 90 days. Our objective was to determine whether a multifaceted population-based intervention resulted in a reduction in recurrent stroke after TIA.

METHODS

In this quasi-experimental health services research intervention study, we implemented a TIA management algorithm across the entire province, centered around a 24-hour physician's TIA hotline and public and health provider education on TIA. From administrative databases, we linked emergency department discharge abstracts to hospital discharge abstracts to identify incident TIAs and recurrent strokes at 90 days across a single payer system with validation of recurrent stroke events. The primary outcome was recurrent stroke; with a secondary composite outcome of recurrent stroke, acute coronary syndrome, and all-cause death. We used an interrupted time series regression analysis of age-adjusted and sex-adjusted stroke recurrence rates after TIA, incorporating a 2-year preimplementation period (2007-2009), a 15-month implementation period, and a 2-year postimplementation period (2010-2012). Logistic regression was used to examine outcomes that did not fit the time series model.

RESULTS

We assessed 6,715 patients preimplementation and 6,956 patients postimplementation. The 90-day stroke recurrence rate in the pre-Alberta Stroke Prevention in TIA and mild Strokes (ASPIRE) period was 4.5% compared with 5.3% during the post-ASPIRE period. There was neither a step change (estimate 0.38; p = 0.65) nor slope change (parameter estimate 0.30; p = 0.12) in recurrent stroke rates associated with the ASPIRE intervention implementation period. Adjusted all-cause mortality (odds ratio 0.71, 95% CI 0.56-0.89) was significantly lower after the ASPIRE intervention.

DISCUSSION

The ASPIRE TIA triaging and management interventions did not further reduce stroke recurrence in the context of an organized stroke system. The apparent lower mortality postintervention may be related to improved surveillance after events identified as TIAs, but secular trends cannot be excluded.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that a standardized population-wide algorithmic triage system for patients with TIA did not reduce recurrent stroke rate.

Cultural Knowledge in Context - People Aged 50 Years and Over Make Sense of a First Fracture and Osteoporosis

Catch a Break (CaB) is a secondary fracture prevention program that uses medical understandings of osteoporosis to assess first fractures and determine appropriateness for secondary fracture prevention. In this study, we interviewed CaB program participants to identify the understandings that patients themselves used to make sense of first fractures and the osteoporosis suggestion as cause. Semi-structured interviews were conducted with female and male participants of the CaB program in Canada. An interpretive practice approach was used to analyze the data. A random sample of 20 individuals, 12 women, and eight men all aged 50 years and over participated. First fractures were produced as meaningful in the context of osteoporosis only for seniors of very advanced age, and for people of any age with poor nutrition. The trauma events that led to a first fracture were produced as meaningful only if perceived as accidents, and having an active lifestyle was produced as beneficial only for mental health and well-being unrelated to osteoporosis. Cultural knowledge shapes, but does not determine, how individuals make sense of their health and illness experiences. Risk prevention program designers should include patients on the design team and be more aware of the presumptive knowledge used to identify individuals at risk of disease.

Accounts of health risk assessment survey administration in the Catch a Break Program: the social construction of osteoporosis risk identification and need for intervention

Catch a Break staff conducting the organizational work of delivering secondary fracture prevention screening conversations drew on cultural and organizational resources to determine eligibility of individuals. They encountered and navigated their way through interactional troubles as they requested participation, assessed trauma risk, and provided lifestyle information.

PURPOSE

We investigated delivery of a population-based type C fracture liaison service for non-hip fractures. The purpose of this study was to examine accounts of how osteoporosis health risk screening interactions were delivered.

METHODS

A pre-determined sample of 5 organizational representatives (program staff) were interviewed by telephone. We analyzed the qualitative data through the lens of interpretive inquiry, informed by discourse analysis, to examine staff's "talk" about conducting the program risk screening conversations.

RESULTS

A dominant finding emerging from CAB staff's accounts of program delivery was the conversational work required to include only those individuals deemed appropriate for the program while managing the survey interaction. Staff talked about specific examples of interactional troubles they experienced as barriers to the smooth and successful risk screening conversation. They drew on cultural and organizational resources as interpretive frameworks to make decisions about individuals and groups at risk and in need of further investigation. They drew on larger ideas about ageism and genderism, judging as inappropriate for participation the oldest old adults, men involved in high risk occupations, and adults aged 50 to 70. Staff also employed interactional resources useful in managing problems in the conversation during the request to participate, trauma risk assessment, and lifestyle/health information provision sequences of the risk screening call.

CONCLUSION

We uncovered areas in the screening interaction that were talked about by staff as problematic to achieving the program objective of identifying and enrolling individuals in the secondary fracture prevention program. By highlighting areas for improvement in program delivery, this study may help to reduce the interactional troubles staff negotiate as they deliver this type of program.

The predictive ability of EQ-5D-3L compared to the LACE index and its association with 30-day post-hospitalization outcomes

PURPOSE

To examine whether the EQ-5D-3L at the time of discharge from hospital provides additional prognostic information above the LACE index for 30-day post-discharge hospital readmission and to explore the association of EQ-5D-3L with readmissions, emergency department (ED) visits, and death within the same period.

METHODS

Using data (n = 495; mean age 62.9 years (SD 18.6), 50.5% female) from a prospective cohort study of patients discharged from medical wards at two university hospitals, the prognostic ability of EQ-5D-3L was examined using C-statistic, Integrated Discrimination Improvement (IDI) Index, and Akaike's Information Criterion (AIC). The associations between EQ-5D-3L dimensions, total sum, index and VAS scores at the time of discharge and 30-day post-discharge ED visits, readmission, and readmission/death were examined using multivariate logistic regression.

RESULTS

At the time of discharge, 58.6% of participants reported problems in mobility, 28.3% in self-care, 62.1% in usual activities, 62.7% in pain/discomfort, and 42.4% in anxiety/depression. Mean (SD) total sum score was 7.9 (2.0), index score was 0.69 (0.21), and VAS score was 63.7 (18.4). In adjusted analyses, mobility, self-care, usual activities, and the total sum score were significantly associated with 30-day readmission and readmission/death. Differences in C-statistic for LACE readmission prediction models with and without EQ-5D-3L were small. AIC analysis suggests that readmission prediction models containing EQ-5D-3L dimensions or scores were more often preferred to those with the LACE index only. IDI analysis indicates that the discrimination slope of readmission prediction models is significantly improved with the addition of mobility, self-care, or the total sum score of the EQ-5D-3L.

CONCLUSION

The EQ-5D-3L, especially the mobility and self-care dimensions as well as the total sum score, improves 30-day readmission prediction of the LACE index and is associated with 30-day readmissions or readmissions/death.

An Outreach Rehabilitation Program for Nursing Home Residents After Hip Fracture May Be Cost-Saving

BACKGROUND

We compared the cost-effectiveness of 10 weeks of outreach rehabilitation (intervention) versus usual care (control) for ambulatory nursing home residents after hip fracture.

METHODS

Enrollment occurred February 2011 through June 2015 in a Canadian metropolitan region. Seventy-seven participants were allocated in a 2:1 ratio to receive a 10-week rehabilitation program (intervention) or usual care (control) (46 intervention; 31 control). Using a payer perspective, we performed main and sensitivity analyses. Health outcome was measured by quality-adjusted life years (QALYs), using the EQ5D, completed at study entry, 3-, 6-, and 12-months. We obtained patient-specific data for outpatient visits, physician claims, and inpatient readmissions; the trial provided rehabilitation utilization/cost data. We estimated incremental cost and incremental effectiveness.

RESULTS

Groups were similar at study entry; the mean age was 87.9 ± 6.6 years, 54 (71%) were female and 58 (75%) had severe cognitive impairment. EQ5D QALYs scores were nonsignificantly higher for intervention participants. Inpatient readmissions were two times higher among controls, with a cost difference of -$3,350/patient for intervention participants, offsetting the cost/intervention participant of $2,300 for the outreach rehabilitation. The adjusted incremental QALYs/patient difference was 0.024 favoring the intervention, with an incremental cost/patient of -$621 for intervention participants; these values were not statistically significant. A sensitivity analysis reinforced these findings, suggesting that the intervention was likely dominant.

CONCLUSION

A 10-week outreach rehabilitation intervention for nursing home residents who sustain a hip fracture may be cost-saving, through reduced postfracture hospital readmissions. These results support further work to evaluate postfracture rehabilitation for nursing home residents.

Patients' Experiences of Nurse Case-Managed Osteoporosis Care: A Qualitative Study

Background:

Osteoporosis is a chronic condition that is often left untreated. Nurse case-managers can double rates of appropriate treatment in those with new fractures. However, little is known about patients’ experiences of a nurse case-managed approach to osteoporosis care.

Objective:

Our aim was to describe patients’ experiences of nurse case-managed osteoporosis care.

Methods:

A qualitative, descriptive design was used. We recruited patients enrolled in a randomized controlled trial of a nurse case-management approach. Individual semi-structured interviews were conducted which were transcribed and analyzed using content analysis. Data were managed with ATLAS.ti version 7.

Results:

We interviewed 15 female case-managed patients. Most (60%) were 60-years or older, 27% had previous fracture, 80% had low bone mineral density tests, and 87% had good osteoporosis knowledge. Three major themes emerged from our analysis: acceptable information to inform decision-making; reasonable and accessible care provided; and appropriate information to meet patient needs.

Conclusions:

This study provides important insights about older female patients’ experiences with nurse case-managed care for osteoporosis. Our findings suggest that this model to osteoporosis clinical care should be sustained and expanded in this setting, if proven effective. In addition, our findings point to the importance of applying patient-centered care across all dimensions of quality to better enhance the patients’ experience of their health care.

Rehabilitation After Hip Fracture for Nursing Home Residents: A Controlled Feasibility Trial

BACKGROUND

This study compared functional outcomes at 3 months after hip fracture surgery between nursing home residents participating in a 10-week outreach rehabilitation program and those receiving usual care. Function, health-related quality of life, and mortality were also compared over 12 months, and outreach program feasibility was assessed.

METHODS

A feasibility trial was undertaken in Canadian nursing homes; of 77 participants, 46 were allocated to Outreach and 31 to Control prior to assessing function or cognition. Outreach participants received 10 weeks of rehabilitation (30 sessions), and Control participants received usual posthospital fracture care in their nursing homes. The primary outcome was the Functional Independence Measure Physical Domain (FIMphysical) score 3 months post-fracture; we also explored FIM Locomotion and Mobility. Secondary outcomes were FIM scores, EQ-5D-3L scores, and mortality over 12 months. Program feasibility was also evaluated.

RESULTS

The mean age was 88.7 ± 7.0 years, 55 (71%) were female, and 58 (75%) had severe cognitive impairment with no significant group differences (p > .14). Outreach participants had significantly higher FIM Locomotion than usual care (p = .02), but no significant group differences were seen in FIMphysical or FIM Mobility score 3 months post-fracture. In adjusted analyses, Outreach participants reported significant improvements in all FIM and EQ-5D-3L scores compared with Control participants over 12 months (p < .05). Mortality did not differ by group (p = .80). Thirty (65%) Outreach participants completed the program.

CONCLUSIONS

Our feasibility trial demonstrated that Outreach participants achieved better locomotion by 3 months post-fracture compared with participants receiving usual postfracture care; benefits were sustained to 12 months post-fracture. In adjusted analyses, Outreach participants also showed sustained benefits in physical function and health-related quality of life.

Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture.

PURPOSE

To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance).

METHODS

Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital.

RESULTS

Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance).

CONCLUSIONS

An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.

Blood pressure reduction in hypertensive acute ischemic stroke patients does not affect cerebral blood flow

The effect of blood pressure (BP) reduction on cerebral blood flow (CBF) in acute ischemic stroke is unknown. We measured regional CBF with perfusion-weighted MRI before and after BP treatment in a three-armed non-randomized prospective controlled trial. Treatment arm assignment was based on acute mean arterial pressure (MAP). Patients with (MAP) >120 mmHg (n = 14) were treated with intravenous labetalol and sublingual (SL) nitroglycerin (labetalol group). Those with MAP 100-120 mmHg (n = 17) were treated with SL nitroglycerin (0.3 mg) ('NTG Group') and those with baseline MAP<100 mmHg (n = 18) were not treated with antihypertensive drugs (untreated group). Forty-nine patients (18 female, mean age 65.3 ± 12.9 years) were serially imaged. Labetalol reduced MAP by 12.5 (5.7-17.7) mmHg, p = 0.0002. MAP remained stable in the NTG (6.0 (0.4-16, p = 0.3) mmHg and untreated groups (-0.3 (-2.3-7.0, p = 0.2) mmHg. The volume of total hypoperfused tissue (CBF<18 ml/100 g/min) did not increase after labetalol (-1.1 ((-6.5)-(-0.2)) ml, p = 0.1), NTG (0 ((-1.5)-4.5) ml, p = 0.72), or no treatment 0.25 ((-10.1)-4.5) ml, p = 0.87). Antihypertensive therapy, based on presenting BP, in acute stroke patients was not associated with an increased volume of total hypoperfused tissue.

Cost-Effectiveness of Osteoporosis Interventions to Improve Quality of Care After Upper Extremity Fracture: Results From a Randomized Trial (C-STOP Trial)

We assessed the cost-effectiveness of two models of osteoporosis care after upper extremity fragility fracture using a high-intensity Fracture Liaison Service (FLS) Case-Manager intervention versus a low-intensity FLS (ie, Active Control), and both relative to usual care. This analysis used data from a pragmatic patient-level parallel-arm comparative effectiveness trial of 361 community-dwelling participants 50 years or older with upper extremity fractures undertaken at a Canadian academic hospital. We used a decision-analytic Markov model to evaluate the cost-effectiveness of the three treatment alternatives. The perspective was health service payer; the analytical horizon was lifetime; costs and health outcomes were discounted by 3%. Costs were expressed in 2016 Canadian dollars (CAD) and the health effect was measured by quality adjusted life years (QALYs). The average age of enrolled patients was 63 years and 89% were female. Per patient cost of the Case Manager and Active Control interventions were $66CAD and $18CAD, respectively. Compared to the Active Control, the Case Manager saved $333,000, gained seven QALYs, and averted nine additional fractures per 1000 patients. Compared to usual care, the Case Manager saved $564,000, gained 14 QALYs, and incurred 18 fewer fractures per 1000 patients, whereas the Active Control saved $231,000, gained seven QALYs, and incurred nine fewer fractures per 1000 patients. Although both interventions dominated usual care, the Case Manager intervention also dominated the Active Control. In 5000 probabilistic simulations, the probability that the Case Manager intervention was cost-effective was greater than 75% whereas the Active Control intervention was cost-effective in less than 20% of simulations. In summary, although the adoption of either of these approaches into clinical settings should lead to cost savings, reduced fractures, and increased quality-adjusted life for older adults following upper extremity fracture, the Case Manager intervention would be the most likely to be cost-effective. © 2019 American Society for Bone and Mineral Research.

Factors associated with pneumococcal vaccination in 2040 people with type 2 diabetes: A cross-sectional study

AIMS

Pneumococcal vaccination is recommended in diabetes because of the high risk for invasive pneumococcal disease and mortality; however, vaccination rates are below recommended targets. This study was conducted to identify possible reasons behind the low rate of vaccine uptake.

METHODS

We examined baseline information from the Alberta Caring for Diabetes study, a prospective cohort study of 2040 adults with type 2 diabetes. Patients were recruited between December 2011 and December 2013. The baseline survey collected information on a wide range of socio-demographic characteristics, disease and management information, as well as health status measurements and health service utilization. Multivariable logistic regression analyses were conducted to identify factors associated with self-reported pneumococcal vaccination status.

RESULTS

Mean age was 64 (SD 11) years, 45% were women, mean duration of diabetes was 12 (SD 10) years, and 1090 (53%) were vaccinated. Age≥65 years (adjusted odds ratio [aOR] 2.52; 95% CI: 1.98-3.20), respiratory disease (aOR 1.50; 95% CI: 1.17-1.93), and cancer (aOR 1.45; 95% CI: 1.08-1.94) were independently associated with pneumococcal vaccination. In addition, women, retirees, people with diabetes≥10 years, people using antihypertensive medications or insulin, and those who had their HbA_1c, kidney function, or their weight or waist circumference measured by a healthcare professional in the past year were more likely to have been vaccinated.

CONCLUSION

Based on this information, future programs aimed at people aged<65 years old, men, those who are currently working, those recently diagnosed with diabetes, and those with few comorbidities could have the most potential for improving pneumococcal vaccine uptake in people with diabetes.

Quality improvement strategies to prevent falls in older adults: a systematic review and network meta-analysis

BACKGROUND

Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear.

METHODS

We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception-April 2017). We included randomised controlled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently.

RESULTS

A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in reducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] -0.11 [95% CI, -0.18 to -0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD -0.27 [95% CI, -0.33 to -0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD -0.19 [95% CI, -0.30 to -0.01]) were both statistically superior compared to usual care.

CONCLUSIONS

Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42013004151).

Adherence to osteoporosis therapy after an upper extremity fracture: a pre-specified substudy of the C-STOP randomized controlled trial

Despite their proven efficacy for secondary fracture prevention, long-term adherence with oral bisphosphonates is poor.

INTRODUCTION

To compare the effectiveness of two interventions on long-term oral bisphosphonate adherence after an upper extremity fragility fracture.

METHODS

Community-dwelling participants 50 years or older with upper extremity fragility fractures not previously treated with bisphosphonates were randomized to either a multi-faceted patient and physician educational intervention (the active control arm) vs. a nurse-led case manager (the study arm). Primary outcome was adherence (taking > 80% of prescribed doses) with prescribed oral bisphosphonates at 12 months postfracture between groups; secondary outcomes included rates of primary non-adherence and 24-month adherence. We also compared quality of life between adherent and non-adherent patients.

RESULTS

By 12 months, adherence with the initially prescribed bisphosphonate was similar (p = 0.96) in both groups: 38/48 (79.2%) in the educational intervention group vs. 66/83 (79.5%) in the case manager arm. By 24 months, adherence rates were 67% (32/48) in the educational intervention group vs. 53% (43/81) in case managed patients (p = 0.13). Primary non-adherence was 6% (11 patients) in the educational intervention group and 12% (21 patients) in the case managed group (p = 0.07). Prior family history of osteoporosis (aOR 2.1, 95% CI 1.0 to 4.4) and being satisfied with current medical care (aOR 2.3, 95% CI 1.1 to 4.8) were associated with better adherence while lower income (aOR 0.2, 95% CI 0.1 to 0.6, for patients with income < $30,000 per annum) was associated with poorer rates of adherence. There were no differences in health-related quality of life scores at baseline or during follow-up between patients who were adherent and those who were not.

CONCLUSION

While both interventions achieved higher oral bisphosphonate adherence compared to previously reported adherence rates in the general population, primary non-adherence and long-term adherence to bisphosphonates were similar in both arms. Adherence was influenced by family history of osteoporosis, satisfaction with current medical care, and income.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT01401556.

Changes in employer-sponsored private health insurance among retirees in Ontario: a cross-sectional study

BACKGROUND

Employer-sponsored health insurance, particularly for retirees with limited incomes, plays a major funding role in Canadian health care, including prescription drugs and dental services. We aimed to investigate the changes in retiree health insurance availability over time.

METHODS

We performed a secondary analysis of data from the 2005 and 2013-2014 cycles of the Canadian Community Health Survey using multivariate logistic regression to study changes in retiree coverage availability over time in Ontario. We estimated the adjusted odds ratios of having employer coverage for likely retirees (people over age 65 yr who reported not working and those over age 75 yr), adjusting for a number of potential confounders. Sensitivity analysis was also performed for coverage of different treatments separately.

RESULTS

The response rate was 76% for the 2005 cycle and 66% for 2013-2014 for the entire survey. The characteristics of respondents in the 2 survey cycles were similar, except respondents in 2013-2014 were wealthier. In our adjusted model, respondents in 2013-2014 had lower odds of reporting retiree coverage than respondents in 2005 (adjusted odds ratio 0.87; 95% confidence interval 0.77-0.99). This represents an absolute reduction in the probability of receiving retiree coverage of up to 3.4%.

INTERPRETATION

Our analysis suggests that the rate of retiree health insurance has declined for Canadians with similar characteristics over the past decade. As we know insurance coverage has a strong association with use of treatments such as prescription drugs and dental care, this decline may result in decreased access to treatment and is an issue that warrants further investigation.

Impact of a household-level deductible on prescription drug use among lower-income adults: a quasi-experimental study

BACKGROUND

Several Canadian public drug plans have income-based deductibles, but we have limited data on their impact, particularly for vulnerable populations. Therefore, we studied the impact of deductibles in British Columbia's Fair PharmaCare program on drug use among lower-income adults.

METHODS

We used a quasi-experimental regression discontinuity design to study the impact of BC rules that impose no deductible before receiving public coverage on households with incomes less than $15 000, a deductible of 2% of household income on those with incomes between $15 000 and $30 000, and a deductible of 3% of household income on those with incomes above $30 000. We studied the impact of these thresholds on public and total drug expenditures between 2003 and 2015 using 24 million person-years of data.

RESULTS

Both thresholds decreased the proportion of beneficiaries receiving benefits, by 0.33 (95% confidence interval [CI] -0.34 to -0.30) and 0.05 (95% CI -0.064 to -0.032) respectively. There were also substantial reductions in the extent of public drug plan expenditures ($59.94 [95% CI -74.74 to -45.14] and $26.12 [95% CI -39.78 to -12.46], respectively). The change at the $15 000 threshold reduced patient drug expenditures by $26.00 (95% CI -45.48 to -6.51), or 7.2%. In contrast, we found no statistically significant change in total expenditures when households moved from a deductible of 2% to 3% at the $30 000 threshold.

INTERPRETATION

Income-based deductibles considerably affected the extent of public subsidy for prescription drugs. For lower-income households making around $15 000, the deductible led to a reduction of 7.2% in overall drug use and costs. Although deductibles are a useful tool to limit public expenditures, policy-makers should be cautious in their use among vulnerable populations.

Comparing Strategies Targeting Osteoporosis to Prevent Fractures After an Upper Extremity Fracture (C-STOP Trial): A Randomized Controlled Trial

We compared osteoporosis care after upper extremity fragility fracture using a low-intensity Fracture Liaison Service (FLS) versus a high-intensity FLS in a pragmatic patient-level parallel-arm comparative effectiveness trial undertaken at a Canadian academic hospital. A low-intensity FLS (active-control) that identified patients and notified primary care providers was compared to a high-intensity FLS (case manager) where a specially-trained nurse identified patients, investigated bone health, and initiated appropriate treatment. A total of 361 community-dwelling participants 50 years or older with upper extremity fractures who were not on bisphosphonate treatment were included; 350 (97%) participants completed 6-month follow-up undertaken by assessors blinded to group allocation. The primary outcome was difference in bisphosphonate treatment between groups 6 months postfracture; secondary outcomes included differences in bone mineral density (BMD) testing and a predefined composite measure termed "appropriate care" (taking or making an informed decision to decline medication for those with low BMD; not taking bisphosphonate treatment for those with normal BMD). Absolute differences (%), relative risks (RR with 95% confidence intervals [CIs]), number-needed-to-treat (NNT), and direct costs were compared. A total of 181 participants were randomized to active-control and 180 to case-manager using computer-generated randomization; the groups were similar on study entry. At 6 months, 51 (28%) active-control versus 86 (48%) case-manager participants started bisphosphonate treatment (20% absolute difference; RR 1.70; 95% CI, 1.28 to 2.24; p < 0.0001; NNT = 5). Of active-controls, 108 (62%) underwent BMD testing compared to 128 (73%) case-managed patients (11% absolute difference; RR 1.17; 95% CI, 1.01 to 1.36; p = 0.03). Appropriate care was received by 76 (44%) active-controls and 133 (76%) case-managed participants (32% absolute difference; RR 1.73; 95% CI, 1.43 to 2.09; p < 0.0001). The direct cost per participant was $18 Canadian (CDN) for the active-control intervention compared to $66 CDN for the case-manager intervention. In summary, case-management led to substantially greater improvements in bisphosphonate treatment and appropriate care within 6 months of fracture than the active control. © 2018 American Society for Bone and Mineral Research.

Engaging patients and primary care providers in the design of novel opinion leader based interventions for acute asthma in the emergency department: a mixed methods study

BACKGROUND

Multifaceted interventions driven by the needs of patients and providers can help move evidence into practice more rapidly. This study engaged both patients and primary care providers (PCPs) to help design novel opinion leader (OL)-based interventions for patients with acute asthma seen in emergency departments (EDs).

METHODS

A mixed methods design was employed. In phase I, we invited convenience samples of patients with asthma presenting to the ED and PCPs to participate in a survey. Perceptions with respect to: a) an ideal OL-profile for asthma guidance; and b) content, style and delivery methods of OL-based interventions in acute asthma directed from the ED were collected. In phase II, we conducted focus groups to further explore preferences and expectations for such interventions with attention to barriers and facilitators for implementation.

RESULTS

Overall, 54 patients completed the survey; 39% preferred receiving guidance from a respirologist, 44% during their ED visit and 56% through individual discussions. In addition, 55% expressed interest in having PCP follow-up within a week of ED discharge. A respirologist was identified as the ideal OL-profile by 59% of the 39 responding PCPs. All expressed interest in receiving notification of their patients' ED presentation, most within a week and including diagnosis and ED/post ED-treatment. Personalized, guideline-based, recommendations were considered to be the ideal content by the majority; 39% requested this guidance through a pamphlet faxed to their offices. In the focus groups, patients and PCPs recognized the importance of health professional liaisons in transitions in care; patient anxiety and PCP time constraints were identified as potential barriers for ED-educational information uptake and proper post-ED follow-up, respectively.

CONCLUSIONS

Engaging patients and PCPs yielded actionable information to tailor OL-based multifaceted interventions for acute asthma in the ED. We identified potential facilitators for the implementation of such interventions (e.g., patient interaction with alternative health care professionals who could facilitate transitions in asthma care between the ED and the primary care setting), and for the provision of post discharge self-management education (e.g., consideration of the first week of ED discharge as a practical time frame for this intervention). Prioritization of identified barriers (e.g., lack of PCP involvement) could be addressed by the identification of potential early adopters in practice environments (e.g., clinicians with special interest in asthma).

Reasons and outcomes for patients receiving ICS/LABA agents prior to, and one month after, emergency department presentations for acute asthma

Objective: Asthma is a common emergency department (ED) presentation. This study examined factors associated with inhaled corticosteroids/long-acting beta-agonist (ICS/LABA) use; and management and outcomes before and after ED presentation. Methods: Secondary analysis of a prospective cohort study; adults treated for acute asthma in Canadian EDs underwent a structured interview before discharge and were followed-up four weeks later. Patients received oral corticosteroids (OCS) at discharge and, at physician discretion, most received ICS or ICS/LABA inhaled agents. Analyses focused on ICS/LABA vs "other" treatment groups at ED presentation. Results: Of 807 enrolled patients, 33% reported receiving ICS/LABA at ED presentation; 62% were female, median age was 31 years. Factors independently associated with ICS/LABA treatment prior to ED presentation were: having an asthma action plan; using an asthma diary/peak flow meter; influenza immunization; not using the ED as usual site for prescriptions; ever using OCS and currently using ICS. Patients were treated similarly in the ED and at discharge; however, relapse was higher in the ICS/LABA group, even after adjustment. Conclusion: One-third of patients presenting to the ED with acute asthma were already receiving ICS/LABA agents; this treatment was independently associated with preventive measures. While ICS/LABA management improves control of chronic asthma, patients using these agents who develop acute asthma reflect higher severity and increased risk of future relapse.

Examining the risk of depression or self-harm associated with incretin-based therapies used to manage hyperglycaemia in patients with type 2 diabetes: a cohort study using the UK Clinical Practice Research Datalink

OBJECTIVES

To compare population-based incidence rates of new-onset depression or self-harm in patients initiating incretin-based therapies with that of sulfonylureas (SU) and other glucose-lowering agents.

DESIGN

Population-based cohort study.

SETTING

Patients attending primary care practices registered with the UK-based Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

Using the UK-based CPRD, we identified two incretin-based therapies cohorts: (1) dipeptidyl peptidase-4 inhibitor (DPP-4i)-cohort, consisting of new users of DPP-4i and SU and (2) glucagon-like peptide-1 receptor agonists (GLP-1RA)-cohort, consisting of new users of GLP-1RA and SU, between January 2007 and January 2016. Patients with a prior history of depression, self-harm and other serious psychiatric conditions were excluded.

MAIN OUTCOME MEASURES

The primary study outcome comprised a composite of new-onset depression or self-harm. Unadjusted and adjusted Cox proportional hazards regression was used to quantify the association between incretin-based therapies and depression or self-harm. Deciles of High-Dimensional Propensity Scores and concurrent number of glucose-lowering agents were used to adjust for potential confounding.

RESULTS

We identified new users of 6206 DPP-4i and 22 128 SU in the DPP-4i-cohort, and 501 GLP-1RA and 16 409 SU new users in the GLP-1RA-cohort. The incidence of depression or self-harm was 8.2 vs 11.7 events/1000 person-years in the DPP-4i-cohort and 18.2 vs 13.6 events/1000 person-years in the GLP-1RA-cohort for incretin-based therapies versus SU, respectively. Incretin-based therapies were not associated with an increased or decreased incidence of depression or self-harm compared with SU (DPP-4i-cohort: unadjusted HR 0.70, 95% CI 0.51 to 0.96; adjusted HR 0.80, 95% CI 0.57 to 1.13; GLP-1RA-cohort: unadjusted HR 1.36, 95% CI 0.72 to 2.58; adjusted HR 1.25, 95% CI 0.63 to 2.50). Consistent results were observed for other glucose-lowering comparators including insulin and thiazolidinediones.

CONCLUSIONS

Our findings suggest that the two incretin-based therapies are not associated with an increased or decreased risk of depression or self-harm.

Invasive pneumococcal disease in Northern Alberta, not a Red Queen but a dark horse

BACKGROUND

The consequences of the introduction of various pneumococcal protein conjugate vaccines (PCV) for children and adults is poorly understood.

OBJECTIVE

We undertook a population-based cohort study of invasive pneumococcal disease (IPD) in Northern Alberta (Canada) from 2000 to 2014, years spanning pre-and early PCV (2000-2004) vs PCV-7 (2005-2009) vs PCV-13 (2010-2014) time periods.

DESIGN

We collected clinical, laboratory, and Streptococcus pneumoniae serotype information on all patients from 2000 to 2014. We determined changes in presentation, outcomes, serotypes, and incidence in children and adults across time periods.

SETTING

There were 509 cases of IPD in children, an 80% decrease over time. Rates of empyema (4.0-15.7%, p < 0.001), ICU admission (13.1-20%), and mortality (1.8-8.4%, p < 0.001) increased over time. There were 2417 cases of IPD in adults. Unlike children, incidence of IPD did not change nor did rates of empyema. ICU admissions increased (p = 0.004) and mortality decreased (18.7-16.5%, p = 0.002). The total number of serotypes causing IPD remained stable in children (22 vs 26 vs 20) while they decreased in adults (49 vs 47 vs 42).

CONCLUSIONS AND RELEVANCE

For children, PCV vaccination strategies resulted in decreased overall rates of IPD and we observed increased rates of empyema and mortality; for adults, there was no change in IPD rates although disease severity increased while mortality decreased. On a population-wide basis, our results suggest that current PCV vaccination strategies are associated with an overall decrease in IPD but disease severity seems to be increasing in both children and adults.

Sustaining knowledge translation interventions for chronic disease management in older adults: protocol for a systematic review and network meta-analysis

BACKGROUND

Failure to sustain knowledge translation (KT) interventions impacts patients and health systems, diminishing confidence in future implementation. Sustaining KT interventions used to implement chronic disease management (CDM) interventions is of critical importance given the proportion of older adults with chronic diseases and their need for ongoing care. Our objectives are to (1) complete a systematic review and network meta-analysis of the effectiveness and cost-effectiveness of sustainability of KT interventions that target CDM for end-users including older patients, clinicians, public health officials, health services managers and policy-makers on health care outcomes beyond 1 year after implementation or the termination of initial project funding and (2) use the results of this review to complete an economic analysis of the interventions identified to be effective.

METHODS

For objective 1, comprehensive searches of relevant electronic databases (e.g. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials), websites of health care provider organisations and funding agencies will be conducted. We will include randomised controlled trials (RCTs) examining the impact of a KT intervention targeting CDM in adults aged 65 years and older. To examine cost, economic studies (e.g. cost, cost-effectiveness analyses) will be included. Our primary outcome will be the sustainability of the delivery of the KT intervention beyond 1 year after implementation or termination of study funding. Secondary outcomes will include behaviour changes at the level of the patient (e.g. symptom management) and clinician (e.g. physician test ordering) and health system (e.g. cost, hospital admissions). Article screening, data abstraction and risk of bias assessment will be completed independently by two reviewers. Using established methods, if the assumption of transitivity is valid and the evidence forms a connected network, Bayesian random-effects pairwise and network meta-analysis will be conducted. For objective 2, we will build a decision analytic model comparing effective interventions to estimate an incremental cost-effectiveness ratio.

DISCUSSION

Our results will inform knowledge users (e.g. patients, clinicians, policy-makers) regarding the sustainability of KT interventions for CDM. Dissemination plan of our results will be tailored to end-users and include passive (e.g. publications, website posting) and interactive (e.g. knowledge exchange events with stakeholders) strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084810.

The diagnostic threshold for osteoporosis impedes fracture prevention in women at high risk for fracture: A registry-based cohort study

The diagnostic threshold for osteoporosis, a bone mineral density (BMD) T-score ≤ -2.5, signals an increased risk for fracture. However, most fragility fractures arise among the majority of women with 'osteopenia' or 'normal' BMD. We hypothesized that a BMD T-score of -2.5, even if not intended as a treatment threshold, paradoxically may create disincentive to initiating treatment of women with osteopenia or normal BMD at high risk for fracture. From a population-based BMD registry covering the Province of Manitoba, Canada, we identified 3735 untreated women aged ≥ 50 years undergoing BMD screening in 2006-2015 found to qualify for Osteoporosis Canada guidelines-based treatment. The main outcome was prescription of an approved osteoporosis medications in the year after BMD testing ascertained from a population-based pharmacy database. We estimated adjusted odds ratios (OR, 95% confidence interval [CI]) for treatment initiation based on BMD, major fracture history (non-traumatic vertebral, hip or multiple fractures), age, and calendar year (to examine the impact of treatment guidelines published in 2010). Among these women, 50% (1853) initiated treatment: 71% with osteoporosis, 21% with osteopenia, and 5% with normal BMD with similar values in those with a prior major fracture (71%, 19%, 5%, respectively). Compared to women with osteoporosis, adjusted ORs for treatment of high risk women with osteopenia or normal BMD alone were 0.10 (95% CI 0.09-0.12) and 0.02 (95% CI 0.01-0.04), respectively, and no higher in women with a prior major fracture (OR 1.00, 95% CI 0.84-1.19) or following introduction of treatment guidelines (p = 0.294). In summary, we found evidence that the diagnostic threshold for osteoporosis may serve as a disincentive to initiation of treatment in many women at high risk for incident fracture.

Concurrent Infection with Hepatitis C Virus and Streptococcus pneumoniae

Little is known about concurrent infection with hepatitis C virus (HCV) and Streptococcus pneumoniae, which causes invasive pneumococcal disease (IPD). We hypothesized that co-infection with HCV and S. pneumoniae would increase risk for death and complications. We captured sociodemographic and serologic data for adults with IPD in a population-based cohort study in northern Alberta, Canada, during 2000–2014. IPD patients infected with HCV were compared with IPD patients not infected with HCV for risk of in-hospital deaths and complications by using multivariable logistic regression. A total of 355 of 3,251 patients with IPD were co-infected with HCV. The in-hospital mortality rate was higher for IPD patients infected with HCV. Prevalence of most IPD-related complications (e.g., cellulitis, acute kidney injury, mechanical ventilation) was also higher in HCV-infected patients. Infection with HCV is common in patients with IPD, and HCV is independently associated with an increased risk for serious illness and death.

Association Between Fluid Balance and Outcomes in Critically Ill Children: A Systematic Review and Meta-analysis

IMPORTANCE

After initial resuscitation, critically ill children may accumulate fluid and develop fluid overload. Accruing evidence suggests that fluid overload contributes to greater complexity of care and worse outcomes.

OBJECTIVE

To describe the methods to measure fluid balance, define fluid overload, and evaluate the association between fluid balance and outcomes in critically ill children.

DATA SOURCES

Systematic search of MEDLINE, EMBASE, Cochrane Library, trial registries, and selected gray literature from inception to March 2017.

STUDY SELECTION

Studies of children admitted to pediatric intensive care units that described fluid balance or fluid overload and reported outcomes of interest were included. No language restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

All stages were conducted independently by 2 reviewers. Data extracted included study characteristics, population, fluid metrics, and outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale. Narrative description of fluid assessment methods and fluid overload definitions was done. When feasible, pooled analyses were performed using random-effects models.

MAIN OUTCOMES AND MEASURES

Mortality was the primary outcome. Secondary outcomes included treatment intensity, organ failure, and resource use.

RESULTS

A total of 44 studies (7507 children) were included in this systematic review and meta-analysis. Of those, 27 (61%) were retrospective cohort studies, 13 (30%) were prospective cohort studies, 3 (7%) were case-control studies, and 1 study (2%) was a secondary analysis of a randomized trial. The proportion of children with fluid overload varied by case mix and fluid overload definition (median, 33%; range, 10%-83%). Fluid overload, however defined, was associated with increased in-hospital mortality (17 studies [n = 2853]; odds ratio [OR], 4.34 [95% CI, 3.01-6.26]; I2 = 61%). Survivors had lower percentage fluid overload than nonsurvivors (22 studies [n = 2848]; mean difference, -5.62 [95% CI, -7.28 to -3.97]; I2 = 76%). After adjustment for illness severity, there was a 6% increase in odds of mortality for every 1% increase in percentage fluid overload (11 studies [n = 3200]; adjusted OR, 1.06 [95% CI, 1.03-1.10]; I2 = 66%). Fluid overload was associated with increased risk for prolonged mechanical ventilation (>48 hours) (3 studies [n = 631]; OR, 2.14 [95% CI, 1.25-3.66]; I2 = 0%) and acute kidney injury (7 studies [n = 1833]; OR, 2.36 [95% CI, 1.27-4.38]; I2 = 78%).

CONCLUSIONS AND RELEVANCE

Fluid overload is common and is associated with substantial morbidity and mortality in critically ill children. Additional research should now ideally focus on interventions aimed to mitigate the potential for harm associated with fluid overload.

Performance of FRAX in clinical practice according to sex and osteoporosis definitions: the Manitoba BMD registry

Among 62,275 women and 6455 men, FRAX stratified risk for incident major osteoporotic fracture (MOF) and incident hip fracture (HF) without sex interaction. Performance was good in those with osteoporosis regardless of how this was defined.

INTRODUCTION

Some studies have reported that FRAX performance differs according to sex and/or osteoporosis definitions. We evaluated whether the performance of FRAX to predict incident MOF and HF in women and men was affected by the presence or absence of osteoporosis defined by World Health Organization (WHO) or National Osteoporosis Foundation (NOF) criteria.

METHODS

We studied women and men age ≥ 40 years with baseline hip and spine DXA scans (1996-2013). Individuals were classified into four non-overlapping subgroups: osteoporosis by WHO criteria, osteoporosis exclusively by NOF criteria, high fracture risk by FRAX (MOF ≥ 20% or HF ≥ 3%, without osteoporosis), and low fracture risk (MOF < 20% and HF < 3% without osteoporosis). In each subgroup, we evaluated stratification (hazard ratios [HR]) and calibration (observed vs predicted 10-year fracture probability) for incident fracture.

RESULTS

The population included 62,275 women (5345 MOF and 1471 HF) and 6455 men (405 MOF and 108 HF). FRAX scores were strongly predictive of MOF (HR per SD: women 2.12, 95% CI 2.06-2.18; men 1.89, 95% CI 1.73-2.08; sex interaction p value = 0.97) and HF (women 4.78, 95% CI 4.44-5.14; men 4.20, 95% CI 3.22-5.49; sex interaction p value = 0.71). FRAX scores gave similar HRs for MOF among the four subgroups (subgroup interaction p value 0.34 for women, 0.22 for men). Observed versus predicted 10-year MOF and HF probability for the defined subgroups demonstrated a high level of concordance for women and men (all r² ≥ 0.9).

CONCLUSIONS

FRAX was a strong and consistent predictor of MOF and HF in both women and men and performed well in those with osteoporosis whether defined by WHO or NOF criteria.

The risk of fragility fractures in new users of dipeptidyl peptidase-4 inhibitors compared to sulfonylureas and other anti-diabetic drugs: A cohort study

AIMS

Mixed evidence exists for the effect of incretin-based therapies on osteoporosis in type-2 diabetes. Therefore, we conducted a cohort study to determine the association between dipeptidyl peptidase-4 (DPP-4) inhibitors and common osteoporotic "fragility fractures" (upper extremity, hip, spine).

METHODS

The UK-based Clinical Practice Research Datalink was used to identify adults without prior fractures receiving a new anti-diabetic drug or a new type-2 diabetes diagnosis between 2007 and 2016. The primary aim was to compare new-users of DPP-4 inhibitors versus new-users of sulfonylureas (SU). The association between DPP-4 inhibitors and incident fractures was estimated using Cox proportional hazards models. Deciles of high-dimensional propensity scores and other anti-diabetic drugs were used as covariates.

RESULTS

We identified 7993 and 26,636 new-users of DPP-4 inhibitors and SUs, respectively. At cohort entry, the mean age was 58.8, 40% were female, mean diabetes duration was 1.3 years, and 42% had A1c > 9%. Over 9 years (mean follow-up = 1.2 years), the incident rate of fragility fractures was lower among DPP-4 versus SU users (3.0/1000 vs. 5.2/1000 person-years; P-value = 0.007). After adjustment, there was no statistically significant difference in fracture risk (hazard ratio adjusted, aHR = 0.80, 95%CI 0.51-1.24; P-value = 0.3125). In a secondary analysis, DPP-4 inhibitors were not associated with a difference in fracture risk compared to insulin (aHR = 0.91, 95%CI 0.40-2.09); however were associated with a lower fracture risk versus thiazolidinediones (aHR = 0.47, 95%CI 0.26-0.83). Sensitivity analyses supported findings.

CONCLUSIONS

DPP-4 inhibitors are not associated with an increased risk of fragility fractures compared with SUs or insulin; however, are associated with a lower risk versus thiazolidinediones.

Measuring improvement in fracture risk prediction for a new risk factor: a simulation

Objective

Improvements in clinical risk prediction models for osteoporosis-related fracture can be evaluated using area under the receiver operating characteristic (AUROC) curve and calibration, as well as reclassification statistics such as the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) statistics. Our objective was to compare the performance of these measures for assessing improvements to an existing fracture risk prediction model. We simulated the effect of a new, randomly-generated risk factor on prediction of major osteoporotic fracture (MOF) for the internationally-validated FRAX^® model in a cohort from the Manitoba Bone Mineral Density (BMD) Registry.

Results

The study cohort was comprised of 31,999 women 50+ years of age; 9.9% sustained at least one MOF in a mean follow-up of 8.4 years. The original prediction model had good discriminative performance, with AUROC = 0.706 and calibration (ratio of observed to predicted risk) of 0.990. The addition of the simulated risk factor resulted in improvements in NRI and IDI for most investigated conditions, while AUROC decreased and changes in calibration were negative. Reclassification measures may give different information than discrimination and calibration about the performance of new clinical risk factors.

Risk of prostate cancer across different racial/ethnic groups in men with diabetes: a retrospective cohort study

AIM

To examine the associations between prostate cancer, diabetes and race/ethnicity.

METHODS

Using administrative data from British Columbia, Canada for the period 1994 to 2012, we identified men aged ≥50 years with and without diabetes. Validated surname algorithms identified men as Chinese, Indian or of other race/ethnicity. Multivariable Cox regression was used to estimate adjusted risks of prostate cancer according to diabetes status and race/ethnicity.

RESULTS

Our cohort of 160 566 men had a mean (sd) age of 64.7 (9.4) years and a median of 9 years' follow-up. The incidence rates of prostate cancer among those with and without diabetes were 177.4 (171.7-183.4) and 216.0 (209.7-222.5) per 1000 person-years, respectively. The incidence among Chinese men was 120.9 (109.2-133.1), among Indian men it was 144.1 (122.8-169.0) and in men of other ethnicity it was 204.8 (200.2-209.5). Diabetes was independently associated with a lower risk of prostate cancer (adjusted hazard ratio 0.82, 95% CI 0.78-0.86), as was Chinese (adjusted hazard ratio 0.54, 95% CI 0.46,0.63) and Indian (adjusted hazard ratio 0.66, 95% CI 0.49,0.89) race/ethnicity; however, there was no statistically significant interaction between diabetes status and race/ethnicity (all P>0.1).

CONCLUSION

Diabetes and Chinese and Indian race/ethnicity were each independently associated with a lower risk of prostate cancer.

Effect of Age on the Manifestations and Outcomes of Invasive Pneumococcal Disease in Adults

BACKGROUND

Although a considerable amount is known about the effect of age on the manifestations and outcomes of pneumonia, the same is not true for invasive pneumococcal disease.

METHODS

This was a prospective observational study of all cases (2435) of invasive pneumococcal disease in adults in Northern Alberta from 2000 to 2014. Rates of invasive pneumococcal disease per 100,000, sociodemographic variables, clinical characteristics, and invasive pneumococcal disease-related outcomes were compared for the following age groups: 17-54, 55-64, 65-74, and ≥75 years.

RESULTS

The rate of invasive pneumococcal disease per 100,000 increased with increasing age. Although only 27.3% of the cases were in those aged ≥65 years, they accounted for 48% of the deaths. The case fatality rate increased with increasing age, from 9.6% for those aged 17-54 years to 31.7% for those aged ≥75 years. The rate of meningitis decreased with increasing age, as did admission to intensive care and use of mechanical ventilation. There was a marked reduction in the rate of invasive pneumococcal disease due to protein conjugate vaccine 7 and protein conjugate vaccine 13 serotypes in those aged ≥55 years but a much smaller decline in rates for those aged 17-54 years. Replacement with non-vaccine serotypes constituted approximately 50% of the cases.

CONCLUSIONS

The rate of invasive pneumococcal disease is highest in the very elderly, and manifestations of invasive pneumococcal disease are influenced by age.

Effects of obesity and diabetes on rate of bone density loss

In this large registry-based study, women with diabetes had marginally greater bone mineral density (BMD) loss at the femoral neck but not at other measurement sites, whereas obesity was not associated with greater BMD loss. Our data do not support the hypothesis that rapid BMD loss explains the increased fracture risk associated with type 2 diabetes and obesity observed in prior studies.

INTRODUCTION

Type 2 diabetes and obesity are associated with higher bone mineral density (BMD) which may be less protective against fracture than previously assumed. Inconsistent data suggest that rapid BMD loss may be a contributing factor.

METHODS

We examined the rate of BMD loss in women with diabetes and/or obesity in a population-based BMD registry for Manitoba, Canada. We identified 4960 women aged ≥ 40 years undergoing baseline and follow-up BMD assessments (mean interval 4.3 years) without confounding medication use or large weight fluctuation. We calculated annualized rate of BMD change for the lumbar spine, total hip, and femoral neck in relation to diagnosed diabetes and body mass index (BMI) category.

RESULTS

Baseline age-adjusted BMD was greater in women with diabetes and for increasing BMI category (all P < 0.001). In women with diabetes, unadjusted BMD loss was less at the lumbar spine (P = 0.017), non-significantly greater at the femoral neck (P = 0.085), and similar at the total hip (P = 0.488). When adjusted for age and BMI, diabetes was associated with slightly greater femoral neck BMD loss (- 0.0018 g/cm²/year, P = 0.012) but not at the lumbar spine or total hip. There was a strong linear effect of increasing BMI on attenuated BMI loss at the lumbar spine with negligible effects on hip BMD.

CONCLUSIONS

Diabetes was associated with slightly greater BMD loss at the femoral neck but not at other measurement sites. BMD loss at the lumbar spine was reduced in overweight and obese women but BMI did not significantly affect hip BMD loss.

The impact of a physician detailing and sampling program for generic atorvastatin: an interrupted time series analysis

BACKGROUND

In 2011, Manitoba implemented a province-wide program of physician detailing and free sampling for generic atorvastatin to increase use of this generic statin. We examined the impact of this unique combined program of detailing and sampling for generic atorvastatin on the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin.

METHODS

We conducted a retrospective study of Manitoba insurance claims data for all continuously enrolled patients who filled one or more prescriptions for a statin between 2008 and 2013. Data were linked to physician-level data on the number of detailing visits and sample provision. We used interrupted time series analyses to assess policy-related changes in the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin.

RESULTS

The detailing program reached 31% (651/2103) of physicians who prescribed a statin during the study period. Collectively, these physicians prescribed 61% of statins dispensed in the province. Free sample cards were provided to 61% (394/651) of the detailed physicians. The program did not change the level or trend in the overall statin use rate and the total cost of statins or increase the number of patients switching from another branded statin to generic atorvastatin. We found the program had a small impact on atorvastatin's market share of new prescriptions, with a level increase of 2.6%.

CONCLUSIONS

Though physician detailers were skilled at targeting high-prescribing physicians, a combined program of detailing visits and sample provision for generic atorvastatin did not lower overall statin costs or lead to switching from branded statins to the generic. The preceding introduction of generic atorvastatin appeared sufficient to modify prescribing patterns and decrease costs.

Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise.

OBJECTIVE

To assess the potential effectiveness of interventions for preventing falls.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned.

STUDY SELECTION

Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older.

DATA EXTRACTION AND SYNTHESIS

Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted.

MAIN OUTCOMES AND MEASURES

Injurious falls and fall-related hospitalizations.

RESULTS

A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], -0.67 [95% CI, -1.10 to -0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, -1.79 [95% CI, -2.63 to -0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, -1.19 [95% CI, -2.04 to -0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, -2.08 [95% CI, -3.56 to -0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]).

CONCLUSIONS AND RELEVANCE

Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

Clinical performance of an updated trabecular bone score (TBS) algorithm in men and women: the Manitoba BMD cohort

This is the first study to directly compare the original and recently updated versions of the trabecular bone score (TBS) algorithm. We confirmed improved performance of the new algorithm, especially among men.

INTRODUCTION

Lumbar spine trabecular bone score (TBS) predicts major osteoporotic fractures (MOFs) and hip fractures (HFs) independent of bone density. The original TBS algorithm (version 1; [TBS-v1]) was optimized for women of average body size. Limitations were identified when used in men or extremes of body mass index (BMI). The current study evaluates an updated TBS algorithm (version 2; [TBS-v2]) modified to address these issues.

METHODS

From a registry with all DXA results for Manitoba, Canada, we identified 47,736 women and 4348 men age ≥ 40 with baseline spine DXA (GE Prodigy, 1999-2011). Spine TBS was measured using both TBS-v1 and TBS-v2 algorithms. Risk stratification for incident fractures identified from population-based data was assessed from area under the receiver operating characteristic curve (AUROC).

RESULTS

With the TBS-v1 algorithm, average TBS for men was significantly lower than for women (p < 0.001) and showed significant inverse correlations with BMI (Pearson r-0.40 in men, -0.18 in women [both p < 0.001]). With the TBS-v2 algorithm, average values for men were slightly greater than for women (p < 0.001) and there were no significant correlations with BMI (Pearson r 0.01 in men, -0.01 in women [both p > 0.1]). During mean follow-up of 5 years in men, there were 214 incident MOFs and 47 HFs; during 6 years mean follow-up in women, there were 2895 incident MOFs and 694 HFs. Improvements in fracture prediction were seen with TBS-v2 in both men (change in AUROC for MOFs +0.021 [p = 0.17], HFs +0.046 [p = 0.04]) and women (change in AUROC for MOFs +0.012 [p < 0.001], HFs +0.020 [p < 0.001]).

CONCLUSION

The updated TBS algorithm is less affected by BMI, gives higher mean results for men than women consistent with their lower fracture risk, and improves fracture prediction in both men and women.

Total Hip Bone Area Affects Fracture Prediction With FRAX® in Canadian White Women

CONTEXT

Areal bone mineral density (BMD) measurements are confounded by skeletal size. Hip BMD is an input to the FRAX® tool (Centre for Metabolic Bone Diseases, University of Sheffield, United Kingdom), but it is unknown whether performance is affected by hip area.

OBJECTIVE

To examine whether fracture prediction by FRAX® is affected by hip area.

DESIGN AND SETTING

Cohort study using a population-based BMD registry.

PATIENTS

A total of 58,108 white women aged ≥40 years.

MAIN OUTCOME MEASURES

Incident major osteoporotic fracture (MOF; n = 4913) and hip fracture (n = 1369), stratified by total hip area quintile, before and after adjustment for hip axis length (HAL).

RESULTS

Smaller hip area was associated with younger age and lower FRAX® scores, whereas incident fractures were greater in those with larger hip area (P for trend < 0.001). Larger hip area quintile increased risk for MOF and hip fracture when adjusted for FRAX® score with BMD (P for trend < 0.001). Each standard deviation increase in hip area was associated with greater risk for incident MOF [adjusted hazard ratio (HR), 1.08; 95% confidence interval (CI), 1.05 to 1.11] and hip fracture (HR, 1.16; 95% CI, 1.11 to 1.21), but not after adjustment for HAL. FRAX® with BMD underestimated MOF risk in the largest hip area quintile and underestimated hip fracture risk in the three largest hip area quintiles.

CONCLUSIONS

In Canadian white women, skeletal size based on hip area affects fracture risk assessment based on FRAX® score with BMD, with risk underestimated in those with larger hip areas. Including HAL in the risk assessment compensates for this confounding by skeletal size and provides for more accurate assessment of fracture risk.

Risk factors for pneumococcal endocarditis

Bacteremia is one of the most common manifestations of invasive pneumococcal disease (IPD). One complication of bacteremia is endocarditis; yet, few studies have evaluated the overall incidence and risk factors for IPD-associated endocarditis. Thus, we evaluated the overall incidence and risk factors of endocarditis compared to those without endocarditis in a large population of IPD patients. We prospectively collected all IPD cases from 2000 to 2014 in Northern Alberta, Canada. Descriptive statistics were used to compare sociodemographic variables, clinical characteristics, and IPD-related outcomes between patients with and without endocarditis. Endocarditis complicated the course of only 28 (0.3%) of 3251 adult patients with IPD. Endocarditis patients were more likely to use illicit drugs and have a higher severity of illness at presentation (i.e., higher rate of altered mental status and rate of intensive care unit [ICU] utilization, p < 0.05); however, no other major risk factors were identified. New murmur development among endocarditis patients was common: 39.3% compared to 2.2% of non-endocarditis patients (p < 0.001). The mortality rate of 39.3% was more than twice that of the rate of 14.7% for the patients with IPD but without endocarditis. There was no pneumococcal serotype predilection for endocarditis. Endocarditis is an uncommon complication of IPD, but, when present, is associated with a significantly increased risk of mortality. Overall, few specific risk factors were identified for IPD-related endocarditis, with the exception of illicit drug use.

Rates of, and risk factors for, septic arthritis in patients with invasive pneumococcal disease: prospective cohort study

BACKGROUND

There are many case reports of septic arthritis complicating invasive pneumococcal disease (IPD); however, no study has compared patients with IPD with septic arthritis to those who didn't develop septic arthritis Thus, we aimed to determine the rates of, and risk factors for, septic arthritis in patients with invasive pneumococcal disease (IPD).

METHODS

Socio-demographic, clinical, and serological data were captured on all patients with IPD in Northern Alberta, Canada from 2000 to 2014. Septic arthritis was identified by attending physicians. Descriptive statistics and multivariate analyses were used to compare characteristics of those with septic arthritis and IPD to those who did not.

RESULTS

Septic arthritis developed in 51 of 3251 (1.6%) of patients with IPD. Inability to walk independently, male sex, and underlying joint disease were risk factors for developing septic arthritis in patients with IPD. Capsular serotypes 22 and 12F were more common in patients with septic arthritis than those without.

CONCLUSIONS

In patients with IPD, septic arthritis is uncommon. Certain risk factors such as walking with or without assistance and underlying joint disease make biological sense as damaged joints are more likely to be infected in the presence of bacteremia.

TRIAL REGISTRATION

Not applicable.

FRAX for fracture prediction shorter and longer than 10 years: the Manitoba BMD registry

In a large clinical registry for the province of Manitoba, Canada, FRAX predicted incident MOF and hip fracture from 1 to 15 years following baseline assessment. A simple linear rescaling of FRAX outputs seems useful for predicting both short- and long-term fracture risk in this population.

INTRODUCTION

FRAX® estimates 10-year probability of major osteoporotic fracture (MOF) and hip fracture. We examined FRAX predictions over intervals shorter and longer than 10 years.

METHODS

Using a population-based clinical registry for Manitoba, Canada, we identified 62,275 women and 6455 men 40 years and older with baseline dual-energy X-ray absorptiometry scans and FRAX scores. Incident MOF and hip fracture were assessed up to 15 years from population-based data. We assessed agreement between estimated fracture probability from 1 to 15 years using linearly rescaled FRAX scores and observed cumulative fracture probability. The gradient of risk for FRAX probability and incident fracture was examined overall and for 5-year intervals.

RESULTS

FRAX predicted incident MOF and hip fracture for all time intervals. There was no attenuation in the gradient of risk for MOF even for years >10. Gradient of risk was slightly lower for hip fracture prediction in years >10 vs years <5, though HRs remained high. Linear agreement was seen in the relationships between observed vs predicted (rescaled) FRAX probabilities (R ² 0.95-1.00). Among women, there was near-perfect linearity in MOF predictions. Deviations from linearity, with a slightly higher observed than predicted MOF probability, were most evident in the first years following a fracture event and after 10 years for hip fracture prediction in women using FRAX with BMD. Simulations showed that results were robust to large differences in fracture rates and moderate differences in mortality rates.

CONCLUSIONS

FRAX predicts incident MOF and hip fracture up to 15 years and could be adapted to predict fracture over time periods shorter and longer term than 10 years in populations with fracture and mortality epidemiology similar to Canada.

Economic evaluation of a population-based osteoporosis intervention for outpatients with non-traumatic non-hip fractures: the "Catch a Break" 1i [type C] FLS

Fracture liaison services (FLS) are advocated to improve osteoporosis treatment after fragility fracture, but there are few economic analyses of different models. A population-based 1i [=type C] FLS for non-hip fractures was implemented and it costs $44 per patient and it was very cost-effective ($9200 per QALY gained). Small operational changes would convert it from cost-effective to cost-saving.

INTRODUCTION

After fragility fracture, <20% of patients receive osteoporosis treatment. FLS are recommended to address this deficit but there are very few economic analyses of different FLS models. Therefore, we conducted an economic analysis of a 1i (=type C) FLS called "Catch a Break (CaB)."

METHODS

CaB is a population-based FLS in Alberta, Canada, that case-finds older outpatients with non-traumatic upper extremity, spine, pelvis, or "other" non-hip fractures and provides telephonic outreach and printed educational materials to patients and their physicians. Cost-effectiveness was assessed using Markov decision-analytic models. Costs were expressed in 2014 Canadian dollars and effectiveness based on model simulations of recurrent fractures and quality-adjusted life years (QALYs). Perspective was healthcare payer; horizon was lifetime; and costs and benefits were discounted 3%.

RESULTS

Over 1 year, CaB enrolled 7323 outpatients (mean age 67 years, 75% female, 69% upper extremity) at average cost of $44 per patient. Compared with usual care, CaB increased rates of bisphosphonate treatment by 4.3 to 17.5% (p < 0.001). Over their lifetime, for every 10,000 patients enrolled in CaB, 4 hip fractures (14 fractures total) would be avoided and 12 QALYs gained. Compared with usual care, incremental cost-effectiveness of CaB was estimated at $9200 per QALY. CaB was cost-effective in 85% of 10,000 probabilistic simulations. Sensitivity analyses showed if "other" fractures were excluded and intervention costs reduced 25% that CaB would become cost-saving.

CONCLUSIONS

A relatively inexpensive population-based 1i (=type C) FLS was implemented in Alberta and it was very cost-effective. If CaB excluded "other" fractures and decreased intervention costs by 25%, it would be cost-saving, as would any FLS that was more effective and less expensive.

Association of Mental Disorders and Related Medication Use With Risk for Major Osteoporotic Fractures

IMPORTANCE

Osteoporotic fractures are a leading cause of disability, costs, and mortality. FRAX is a tool used to assess fracture risk in the general population. Mental disorders and medications to treat them have been reported to adversely affect bone health, but, to date, they have not been systematically studied in relation to osteoporotic fractures.

OBJECTIVE

To examine the association of mental disorders and psychotropic medication use with osteoporotic fracture risk in routine clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

In this population-based cohort study, bone mineral density and risk factors were used to calculate FRAX scores using data from the Manitoba Bone Density Program database of all women and men 40 years of age or older in Manitoba, Canada, referred for a baseline dual-energy x-ray absorptiometry scan from January 1, 1996, to March 28, 2013. Population-based health services data were used to identify primary mental disorders during the 3 prior years, psychotropic medication use during the prior year, and incident fractures. Cox proportional hazards regression models estimated the risk for incident fractures based on mental disorders and use of psychotropic medications. Data analysis was conducted from November 25, 2013, to October 15, 2016.

MAIN OUTCOMES AND MEASURES

Incident nontraumatic major osteoporotic fractures (MOFs) and hip fractures.

RESULTS

Of the 68 730 individuals (62 275 women and 6455 men; mean age, 64.2 [11.2] years) in the study, during 485 322 person-years (median, 6.7 years) of observation, 5750 (8.4%) sustained an incident MOF, 1579 (2.3%) sustained an incident hip fracture, and 8998 (13.1%) died. In analyses adjusted for FRAX score, depression was associated with MOF (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.27-1.51; P < .05) and hip fracture (aHR, 1.43; 95% CI, 1.22-1.69; P < .05) before adjustment for medication use, but these associations were not significant after adjustment for medication use. In contrast, the use of selective serotonin reuptake inhibitors (aHR for MOF, 1.43; 95% CI, 1.27-1.60; P < .05; aHR for hip fracture, 1.48; 95% CI, 1.18-1.85; P < .05), antipsychotics (aHR for MOF, 1.43; 95% CI, 1.15-1.77; P < .05; aHR for hip fracture, 2.14; 95% CI, 1.52-3.02; P < .05), and benzodiazepines (aHR for MOF, 1.15; 95% CI, 1.04-1.26; P < .05; aHR for hip fracture, 1.24; 95% CI, 1.05-1.47; P < .05) were each independently associated with significantly increased risk for both MOF and hip fracture. FRAX significantly underestimated the 10-year risk of MOF by 29% and of hip fracture by 51% for those with depression. It also underestimated the 10-year risk of MOF by 36% for use of selective serotonin reuptake inhibitors, by 63% for use of mood stabilizers, by 60% for use of antipsychotics, and by 13% for use of benzodiazepines. FRAX underestimated the 10-year risk of hip fracture by 57% for use of selective serotonin reuptake inhibitors, by 98% for use of mood stabilizers, by 171% for use of antipsychotics, and by 31% for use of benzodiazepines. FRAX correctly estimated fracture risk in people without mental disorders and those not taking psychotropic medications.

CONCLUSIONS AND RELEVANCE

Mental disorders and medication use were associated with an increased risk for fracture, but in simultaneous analyses, only medication use was independently associated with fracture. Depression and psychotropic medication use are potential risk indicators that are independent of FRAX estimates.

Impact of income-based deductibles on drug use and health care utilization among older adults

BACKGROUND

Income-based deductibles are present in several provincial public drug plans in Canada and have been the subject of extensive debate. We studied the impact of such deductibles in British Columbia's Fair PharmaCare plan on drug and health care utilization among older adults.

METHODS

We used a quasi-experimental regression discontinuity design to compare the impact of deductibles in BC's PharmaCare plan between older community-dwelling adults registered for the plan who were born in 1928 through 1939 (no deductible) and those born in 1940 through 1951 (deductible equivalent to 2% of household income). We used 1.2 million person-years of data between 2003 and 2015 to study public drug plan expenditures, overall drug use, and physician and hospital resource utilization in these 2 groups.

RESULTS

The income-based deductible led to a 28.6% decrease in person-years in which public drug plan benefits were received (95% confidence interval [CI] -29.7% to -27.5%) and to a reduction in the per capita extent of annual benefits by $205.59 (95% CI -$247.81 to -$163.37). Despite this difference in public subsidy, we found no difference in the number of drugs received or in total drug spending once privately paid amounts were accounted for (p = 0.4 and 0.8, respectively). Further, we found only small or nonexistent changes in health care resource utilization at the 1939 threshold.

INTERPRETATION

A modest income-based deductible had a considerable impact on the extent of public subsidy for prescription drugs. However, it had only a trivial impact on overall access to medicines and use of other health services. Unlike copayments, modest income-based deductibles may safely reduce public spending on drugs for some population groups.

Accuracy of Offspring-Reported Parental Hip Fractures: A Novel Population-Based Parent-Offspring Record Linkage Study

The objective of this study was to test the validity of offspring-reported parental hip fracture in a unique bone mineral density (BMD) registry linked to administrative databases spanning 4 decades. Population-based data were from Manitoba, Canada, and included hospital abstracts, health insurance registrations, and the provincewide BMD registry. The cohort included individuals aged ≥40 years with BMD tests and self-reports of parental hip fracture between 2006 and 2014. Population registry data for 1966-2014 were used to link offspring with their parents, and hospital records were used to ascertain parental fractures. Overall, 8,112 offspring met the inclusion criteria; 13.6% had a parental hip fracture diagnosis in administrative data during an average of 32.9 years of follow-up. Agreement between parental hip fracture from offspring reports and diagnoses in administrative data was good (κ = 0.68). The sensitivity of offspring reports was 0.70 (95% confidence interval: 0.67, 0.73), and specificity was 0.96 (95% confidence interval: 0.96, 0.97). Offspring characteristics associated with disagreement included male sex, northern rural residence, early BMD test year, and longer interval between BMD test and parental hip fracture diagnosis. This proof-of-concept study focused on hip fractures, but use of record linkage techniques to validate offspring-reported parental information can be extended to other conditions.

Comparative effectiveness and safety of gastric bypass, sleeve gastrectomy and adjustable gastric banding in a population-based bariatric program: prospective cohort study

BACKGROUND

Bariatric surgery in Canada is primarily delivered within publicly funded specialty clinics. Previous studies have demonstrated that bariatric surgery is superior to intensive medical management for reduction of weight and obesity-related comorbidities. Our objective was to compare the effectiveness and safety of laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (LSG) and adjustable gastric banding (LAGB) in a publicly funded, population-based bariatric treatment program.

METHODS

We followed consecutive bariatric surgery patients for 2 years. The primary outcome was weight change (in kilograms). Between-group changes were analyzed using multivariable regression. Last-observation-carried-forward imputation was used for missing data.

RESULTS

We included 150 consecutive patients (51 RYGB; 51 LSG; 48 LAGB) in our study. At baseline, mean age was 43.5 ± 9.5 years, 87.3% of patients were women, and preoperative body mass index (BMI) was 46.2 ± 7.4. Absolute and relative (% of baseline) weight loss at 2 years were 36.6 ± 19.5 kg (26.1 ± 12.2%) for RYGB, 21.4 ± 16.0 kg (16.4 ± 11.6%) for LSG and 7.0 ± 9.7 kg (5.8 ± 7.9%) for LAGB (p < 0.001). Change in BMI was greater for the RYGB (-13.0 ± 6.6) than both the LSG (-7.6 ± 5.7) and the LAGB (-2.6 ± 3.5) groups (p < 0.001). The reduction in diabetes, hypertension and dyslipidemia was greater after RYGB than after LAGB (all p < 0.05). There were no deaths. The anastomotic and staple leakage rate was 1.3%.

CONCLUSION

In a publicly funded, population-based bariatric surgery program, RYGB and LSG demonstrated greater weight loss than the LAGB procedure. Bypass resulted in the greatest reduction in obesity-related comorbidities. All procedures were safe.

Objectively-Verified Parental Non-Hip Major Osteoporotic Fractures and Offspring Osteoporotic Fracture Risk: A Population-Based Familial Linkage Study

Parental hip fracture (HF) is associated with increased risk of offspring major osteoporotic fractures (MOFs; comprising hip, forearm, clinical spine or humerus fracture). Whether other sites of parental fracture should be used for fracture risk assessment is uncertain. The current study tested the association between objectively-verified parental non-hip MOF and offspring incident MOF. Using population-based administrative healthcare data for the province of Manitoba, Canada, we identified 255,512 offspring with linkage to at least one parent (238,054 mothers and 209,423 fathers). Parental non-hip MOF (1984-2014) and offspring MOF (1997-2014) were ascertained with validated case definitions. Time-dependent multivariable Cox proportional hazards regression models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs). During a median of 12 years of offspring follow-up, we identified 7045 incident MOF among offspring (3.7% and 2.5% for offspring with and without a parental non-hip MOF, p < 0.001). Maternal non-hip MOF (HR 1.27; 95% CI, 1.19 to 1.35), paternal non-hip MOF (HR 1.33; 95% CI, 1.20 to 1.48), and any parental non-hip MOF (HR 1.28; 95% CI, 1.21 to 1.36) were significantly associated with offspring MOF after adjusting for covariates. The risk of MOF was even greater for offspring with both maternal and paternal non-hip MOF (adjusted HR 1.61; 95% CI, 1.27 to 2.02). All HRs were similar for male and female offspring (all p_interaction >0.1). Risks associated with parental HF only (adjusted HR 1.26; 95% CI, 1.13 to 1.40) and non-hip MOF only (adjusted HR 1.26; 95% CI, 1.18 to 1.34) were the same. The strength of association between any parental non-hip MOF and offspring MOF decreased with older parental age at non-hip MOF (p_trend  = 0.028). In summary, parental non-hip MOF confers an increased risk for offspring MOF, but the strength of the relationship decreases with older parental age at fracture. © 2016 American Society for Bone and Mineral Research.

Association of Preference-Based Health-Related Quality of Life with Weight Loss in Obese Adults

BACKGROUND

The obesity epidemic is linked to substantial health care resource use, reduction in workforce and home productivity, and poor health-related quality of life (HRQOL). Changes in body mass index (BMI) are associated with improvements in HRQOL; the nature of this relationship, however, has not been reliably described.

OBJECTIVES

To determine the independent association between changes in BMI and change in utility-based HRQOL.

METHODS

Data were prospectively collected on 500 severely obese adult patients enrolled in a single-center obesity management clinic. Univariable and multivariable linear regressions were performed, adjusting for the effect of the intervention itself, obesity-related comorbidities, BMI at enrollment, age, and sex.

RESULTS

A 1-unit reduction in BMI was associated with a 0.0075 (95% confidence interval 0.0041-0.0109) increase in the EuroQol five-dimensional questionnaire score. This relationship was unaltered in various analyses, and is likely applicable to any health-care-induced changes in BMI.

CONCLUSIONS

The quantification of this association advances the understanding of the clinical benefits of interventions that affect BMI, and can inform more robust cost-utility analyses.

Invasive Pneumococcal Disease: Still Lots to Learn and a Need for Standardized Data Collection Instruments

Background. Large studies of invasive pneumococcal disease (IPD) are frequently lacking detailed clinical information. Methods. A population-based 15-year study of IPD in Northern Alberta. Results. 2435 patients with a mean age of 54.2 years formed the study group. Males outnumbered females and Aboriginal and homeless persons were overrepresented. High rates of smoking, excessive alcohol use, and illicit drug use were seen. Almost all (87%) had a major comorbidity and 15% had functional limitations prior to admission. Bacteremia, pneumonia, and meningitis were the most common major manifestations of IPD. Almost half of the patients had alteration of mental status at the time of admission and 22% required mechanical ventilation. Myocardial infarction, pulmonary embolism, and new onset stroke occurred in 1.7, 1.3, and 1.1% of the patients, respectively; of those who had echocardiograms, 35% had impaired ventricular function. The overall in-hospital mortality was 15.6%. Conclusions. IPD remains a serious infection in adults. In addition to immunization, preventative measures need to consider the sociodemographic features more carefully. A standard set of data need to be collected so that comparisons can be made from study to study. Future investigations should target cardiac function and pulmonary embolism prevention in this population.

Change in Trabecular Bone Score (TBS) With Antiresorptive Therapy Does Not Predict Fracture in Women: The Manitoba BMD Cohort

Bone mineral density (BMD) and trabecular bone score (TBS), along with additional clinical risk factors, can be used to identify individuals at high fracture risk. Whether change in TBS in untreated or treated women independently affects fracture risk is unclear. Using the Manitoba (Canada) DXA Registry containing all BMD results for the population we identified 9044 women age ≥40 years with two consecutive DXA scans and who were not receiving osteoporosis treatment at baseline (baseline mean age 62 ± 10 years). We examined BMD and TBS change, osteoporosis treatment, and incident major osteoporotic fractures (MOFs) for each individual. Over a mean of 7.7 years follow-up, 770 women developed an incident MOF. During the interval between the two DXA scans (mean, 4.1 years), 5083 women initiated osteoporosis treatment (bisphosphonate use 80%) whereas 3961 women did not receive any osteoporosis treatment. Larger gains in both BMD and TBS were seen in women with greater adherence to osteoporosis medication (p for trend <0.001), and the magnitude of the increase was consistently greater for BMD than for TBS. Among treated women there was greater antifracture effect for each SD increase in total hip BMD change (fracture decrease 20%; 95% CI, 13% to 26%; p < 0.001), femoral neck BMD change (19%; 95% CI, 12% to 26%; p < 0.001), and lumbar spine BMD change (9%; 95% CI, 0% to 17%; p = 0.049). In contrast, change in TBS did not predict fractures in women who initiated osteoporosis treatment (p = 0.10). Among untreated women neither change in BMD or TBS predicted fractures. We conclude that, unlike antiresorptive treatment-related changes in BMD, change in lumbar spine TBS is not a useful indicator of fracture risk irrespective of osteoporosis treatment. © 2016 American Society for Bone and Mineral Research.

Associations Between Fluid Balance and Outcomes in Critically Ill Children: A Protocol for a Systematic Review and Meta-analysis

Background:

Fluid therapy is a mainstay during the resuscitation of critically ill children. After initial stabilization, excessive fluid accumulation may lead to complications of fluid overload, which has been independently associated with increased risk for mortality and major morbidity in critically ill children.

Objectives:

Perform an evidence synthesis to describe the methods used to measure fluid balance, define fluid overload, and evaluate the association between fluid balance and outcomes in critically ill children.

Design:

Systematic review and meta-analysis.

Measurements:

Fluid balance, fluid accumulation, and fluid overload as defined by authors.

Methods:

We will search Ovid MEDLINE, Ovid EMBASE, Cochrane Library, and ProQuest, Dissertations and Theses. In addition, we will search www.clinicaltrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and the proceedings of selected key conferences for ongoing and completed studies. Search strategy will be done in consultation with a research librarian. Clinical trials and observational studies (from database inception to present) in patients (<25 years) admitted to pediatric intensive care units (PICUs) reporting fluid balance, fluid accumulation, or fluid overload, and associated outcomes will be included. Language will not be restricted. Two reviewers will independently screen studies and extract data. Primary outcome is mortality, and secondary outcomes encompass critical care resource utilization. Quality of evidence and risk of bias will be assessed using the Newcastle-Ottawa Scale (NOS). Results will be synthesized qualitatively and pooled for meta-analysis if possible.

Limitations:

Quality of the included studies; lack of randomized trials; high degrees of expected heterogeneity; and variations in definitions of fluid balance and fluid overload between studies.

Conclusion:

We will comprehensively appraise and summarize the evidence of the association between fluid balance and outcomes in critically ill children, and in doing so attempt to harmonize definitions related to fluid balance, accumulation, and overload.

Systematic review registration:

PROSPERO: CRD42016036209.

Risk of heart failure after community acquired pneumonia: prospective controlled study with 10 years of follow-up

Objective To determine the attributable risk of community acquired pneumonia on incidence of heart failure throughout the age range of affected patients and severity of the infection.Design Cohort study.Setting Six hospitals and seven emergency departments in Edmonton, Alberta, Canada, 2000-02.Participants 4988 adults with community acquired pneumonia and no history of heart failure were prospectively recruited and matched on age, sex, and setting of treatment (inpatient or outpatient) with up to five adults without pneumonia (controls) or prevalent heart failure (n=23 060).Main outcome measures Risk of hospital admission for incident heart failure or a combined endpoint of heart failure or death up to 2012, evaluated using multivariable Cox proportional hazards analyses.Results The average age of participants was 55 years, 2649 (53.1%) were men, and 63.4% were managed as outpatients. Over a median of 9.9 years (interquartile range 5.9-10.6), 11.9% (n=592) of patients with pneumonia had incident heart failure compared with 7.4% (n=1712) of controls (adjusted hazard ratio 1.61, 95% confidence interval 1.44 to 1.81). Patients with pneumonia aged 65 or less had the lowest absolute increase (but greatest relative risk) of heart failure compared with controls (4.8% v 2.2%; adjusted hazard ratio 1.98, 95% confidence interval 1.5 to 2.53), whereas patients with pneumonia aged more than 65 years had the highest absolute increase (but lowest relative risk) of heart failure (24.8% v 18.9%; adjusted hazard ratio 1.55, 1.36 to 1.77). Results were consistent in the short term (90 days) and intermediate term (one year) and whether patients were treated in hospital or as outpatients.Conclusion Our results show that community acquired pneumonia substantially increases the risk of heart failure across the age and severity range of cases. This should be considered when formulating post-discharge care plans and preventive strategies, and assessing downstream episodes of dyspnoea.