CMAJ open最新文献

Background: Recent randomized trials have suggested that endovascular thrombectomy (EVT) alone may provide similar functional outcomes as the current standard of care, EVT combined with intravenous alteplase treatment, for acute ischemic stroke secondary to large vessel occlusion. We conducted an economic evaluation of these 2 therapeutic options.

Methods: We constructed a decision analytic model with a hypothetical cohort of 1000 patients to assess the cost-effectiveness of EVT with intravenous alteplase treatment versus EVT alone for acute ischemic stroke secondary to large vessel occlusion from both the societal and public health care payer perspectives. We used studies and data published in 2009-2021 for model inputs, and acquired cost data for Canada and China, representing high- and middle-income countries, respectively. We calculated incremental cost-effectiveness ratios (ICERs) using a lifetime horizon and accounted for uncertainty using 1-way and probabilistic sensitivity analyses. All costs are reported in 2021 Canadian dollars.

Results: In Canada, the difference in quality-adjusted life-years (QALYs) gained between EVT with alteplase and EVT alone was 0.10 from both the societal and health care payer perspectives. The difference in cost was $2847 from a societal perspective and $2767 from the payer perspective. In China, the difference in QALYs gained was 0.07 from both perspectives, and the difference in cost was $1550 from the societal perspective and $1607 from the payer perspective. One-way sensitivity analyses showed that the distributions of modified Rankin Scale scores at 90 days after stroke were the most influential factor on ICERs. For Canada, compared to EVT alone, the probability that EVT with alteplase would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained was 58.7% from a societal perspective and 58.4% from a payer perspective. The corresponding values for at a willingness-to-pay threshold of $47 185 (3 times the Chinese gross domestic product per capita in 2021) were 65.2% and 67.4%.

Interpretation: For patients with acute ischemic stroke due to large vessel occlusion eligible for immediate treatment with both EVT alone and EVT with intravenous alteplase treatment, it is uncertain whether EVT with alteplase is cost-effective compared to EVT alone in Canada and China.

Background: The "long tail" of the COVID-19 pandemic will be reflected in disabling symptoms that persist, fluctuate or recur for extended periods for an estimated 20%-30% of those who had a SARS-CoV-2 infection; development of effective interventions to address these symptoms must account for the realities faced by these patients. We sought to describe the lived experience of patients living with persistent post-COVID-19 symptoms.

Methods: We conducted a qualitative study, using interpretive description, of the lived experiences of adults experiencing persistent post-COVID-19 symptoms. We collected data from in-depth, semistructured virtual focus groups in February and March 2022. We used thematic analysis to analyze the data and met with several participants twice for respondent validation.

Results: The study included 41 participants (28 females) from across Canada with a mean age of 47.9 years and mean time since initial SARS-CoV-2 infection of 15.8 months. Four overarching themes were identified: the unique burdens of living with persistent post-COVID-19 symptoms; the complex nature of patient work in managing symptoms and seeking treatment during recovery; erosion of trust in the health care system; and the process of adaptation, which included taking charge and transformed self-identity.

Interpretation: Living with persistent post-COVID-19 symptoms within a health care system ill-equipped to provide needed resources profoundly challenges the ability of survivors to restore their well-being. Whereas policy and practice increasingly emphasize the importance of self-management within the context of post-COVID-19 symptoms, new investments that enhance services and support patient capacity are required to promote better outcomes for patients, the health care system and society.

Background: Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms.

Methods: We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger's online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms.

Results: A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1).

Interpretation: Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.

Background: To date, there has been little research on the effect of safe consumption site and community-based naloxone programs on regional opioid-related emergency department visits and deaths. We sought to determine the impact of these interventions on regional opioid-related emergency department visit and death rates in the province of Alberta.

Methods: We used a retrospective observational design, via interrupted time series analysis, to assess municipal opioid-related emergency department visit volume and opioid-related deaths (defined by poisoning and opioid use disorder). We compared rates before and after program implementation in individual Alberta municipalities and province-wide after safe consumption site (March 2018 to October 2018) and community-based naloxone (January 2016) program implementation.

Results: A total of 24 107 emergency department visits and 2413 deaths were included in the study. After safe consumption site opening, we saw decreased opioid-related emergency department visits in Calgary (level change -22.7 [-20%] visits per month, 95% confidence interval [CI] -29.7 to -15.8) and Lethbridge (level change -8.8 [-50%] visits per month, 95% CI -11.7 to -5.9), and decreased deaths in Edmonton (level change -5.9 [-55%] deaths per month, 95% CI -8.9 to -2.9). We observed increased emergency department visits after community-based naloxone program implementation in urban Alberta (level change 38.9 [46%] visits, 95% CI 33.3 to 44.4). We also observed an increase in urban opioid-related deaths (level change 9.1 [40%] deaths, 95% CI 6.7 to 11.5).

Interpretation: The results of this study suggest differences exist between municipalities employing similar interventions. Our results also suggest contextual variation; for example, illicit drug supply toxicity may modify the ability of a community-based naloxone program to prevent opioid overdose without a thorough public health response.

Background: Although language concordance between patients and primary care physicians results in better quality of care and health outcomes, little research has explored inequities in travel burden to access primary care people of linguistic minority groups in Canada. We sought to investigate the travel burden of language-concordant primary care among people who speak French but not English (French-only speakers) and the general public in Ottawa, Ontario, and any inequities in access across language groups and neighbourhood ruralities.

Methods: Using a novel computational method, we estimated travel burden to language-concordant primary care for the general population and French-only speakers in Ottawa. We used language and population data from Statistics Canada's 2016 Census, neighbourhood demographics from the Ottawa Neighbourhood Study, and collected the main practice location and language of primary care physicians from the College of Physicians and Surgeons of Ontario. We measured travel burden using Valhalla, an open-source road-network analysis platform.

Results: We included data from 869 primary care physicians and 916 855 patients. Overall, French-only speakers faced greater travel burdens than the general population to access language-concordant primary care. Median differences in travel burden were statistically significant but small (median difference in drive time 0.61 min, p < 0.001, interquartile range 0.26-1.17 min), but inequities in travel burden between groups were larger among people living in rural neighbourhoods.

Interpretation: French-only speakers in Ottawa face modest - but statistically significant - overall inequities in travel burden when accessing primary care, compared with the general population, and higher inequities in specific neighbourhoods. Our results are of interest to policy-makers and health system planners, and our methods can be replicated and used as comparative benchmarks to quantify access disparities for other services and regions across Canada.

Background: It is unclear whether the benefits of administration of antenatal corticosteroids in late preterm gestation outweigh its harms. We sought to understand whether patients and physicians need increased support to decide whether to administer antenatal corticosteroids in late preterm gestation, and their informational needs and preferences for decision-making roles related to this intervention; we also wanted to know if creation of a decision-support tool would be useful.

Methods: We conducted individual, semistructured interviews with pregnant people, obstetricians and pediatricians in Vancouver, Canada, in 2019. Using a qualitative framework analysis method, we coded, charted and interpreted interview transcripts into categories that formed an analytical framework.

Results: We included 20 pregnant participants, 10 obstetricians and 10 pediatricians. We organized codes into the following categories: informational needs to decide whether to administer antenatal corticosteroids; preferences for decision-making roles regarding this treatment; the need for support to make this treatment decision; and the preferred format and content of a decision-support tool. Pregnant participants wanted to be involved in decision-making about antenatal corticosteroids in late preterm gestation. They wanted information on the medication, respiratory distress, hypoglycemia, parent-neonate bonding and long-term neurodevelopment. There was variation in physician counselling practices, and in how patients and physicians perceived the balance of treatment harms and benefits. Responses suggested a decision-support tool may be useful. Participants desired clear descriptions of risk magnitude and uncertainty.

Interpretation: Pregnant people and physicians would likely benefit from increased support to consider the harms and benefits of antenatal corticosteroids in late preterm gestation. Creation of a decision-support tool may be useful.

Background: Previous research has shown that cocaine-associated deaths occur more frequently in hot weather, which has not been described for other illicit drugs or combinations of drugs. The study objective was to evaluate the relation between temperature and risk of death related to cocaine, opioids and amphetamines in British Columbia, Canada.

Methods: We extracted data on all deaths with cocaine, opioid or amphetamine toxicity recorded as an underlying or contributing cause from BC vital statistics for 1998-2017. We used a time-stratified case-crossover design to estimate the effect of temperature on the risk of death associated with acute drug toxicity during the warmer months (May through September). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for each 10°C increase in the 2-day average maximum temperature at the residential location.

Results: We included 4913 deaths in the analyses. A 10°C increase in the 2-day average maximum temperature was associated with an OR of 1.43 (95% CI 1.11-1.86) for deaths with only cocaine toxicity recorded (n = 561), an OR of 1.15 (95% CI 0.99-1.33) for deaths with opioids only (n = 1682) and an OR of 1.11 (95% CI 0.60-2.04) for deaths with amphetamines only (n = 133). There were also elevated effects when toxicity from multiple drugs was recorded. Sensitivity analyses showed differences in the ORs by sex, by climatic region, and when the location of death was used instead of the location of residence.

Interpretation: Increasing temperatures were associated with higher odds of death due to drug toxicity, especially for cocaine alone and combined with other drugs. Targeted interventions are necessary to prevent death associated with toxic drug use during hot weather.

Background: The COVID-19 pandemic has created major disruptions in cancer care, with reductions in diagnostic tests and treatments. We evaluated the impact of these health care-related changes on cancer staging by comparing cancers staged before and during the pandemic.

Methods: We performed a retrospective cohort study at London Health Sciences Centre and St. Joseph's Health Care London, London, Ontario, Canada. We evaluated all pathologically staged breast, colorectal, prostate, endometrial and lung cancers (the 5 most common cancers by site, excluding nonmelanoma skin cancer) over a 3-year period (Mar. 15, 2018-Mar. 14, 2021). The pre-COVID-19 group included procedures performed between Mar. 15, 2018, and Mar. 14, 2020, and the COVID-19 group included procedures performed between Mar. 15, 2020, and Mar. 14, 2021. The primary outcome was cancer stage group, based on the pathologic tumour, lymph node, metastasis system. We performed univariate analyses to compare demographic characteristics, pathologic features and cancer stage between the 2 groups. We performed multivariable ordinal regression analyses using the proportional odds model to evaluate the association between stage and timing of staging (before v. during the pandemic).

Results: There were 4055 cases across the 5 cancer sites. The average number of breast cancer staging procedures per 30 days increased during the pandemic compared to the yearly average in the pre-COVID-19 period (41.3 v. 39.6), whereas decreases were observed for endometrial cancer (15.9 v. 16.4), colorectal cancer (21.8 v. 24.3), prostate cancer (13.6 v. 18.5) and lung cancer (11.5 v. 15.9). For all cancer sites, there were no statistically significant differences in demographic characteristics, pathologic features or cancer stage between the 2 groups (p > 0.05). In multivariable regression analysis, for all cancer sites, cases staged during the pandemic were not associated with higher stage (breast: odds ratio [OR] 1.071, 95% confidence interval [CI] 0.826-1.388; colorectal: OR 1.201, 95% CI 0.869-1.661; endometrium: OR 0.792, 95% CI 0.495-1.252; prostate: OR 1.171, 95% CI 0.765-1.794; and lung: OR 0.826, 95% CI 0.535-1.262).

Interpretation: Cancer cases staged during the first year of the COVID-19 pandemic were not associated with higher stage; this likely reflects the prioritization of cancer procedures during times of reduced capacity. The impact of the pandemic period on staging procedures varied between cancer sites, which may reflect differences in clinical presentation, detection and treatment.

Background: Sodium-glucose cotransporter-2 (SGLT2) inhibitors are cardioprotective agents in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease (CVD). Since little is known about their uptake in atherosclerotic CVD, we examined SGLT2 inhibitor prescribing trends and identified potential disparities in prescribing patterns.

Methods: We conducted an observational study using linked population-based health data in Ontario, Canada, from April 2016 to March 2020 of patients aged 65 years or older with concomitant type 2 diabetes and atherosclerotic CVD. To examine prevalent prescribing of SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin), we constructed 4 cross-sectional yearly cohorts from Apr. 1 to Mar. 31 (2016/17, 2017/18, 2018/19 and 2019/20). We estimated prevalent SGLT2 inhibitor prescribing by year and by subgroups, and identified factors associated with SGTL2 inhibitor prescribing using multivariable logistic regression.

Results: There were 208 303 patients in our overall cohort (median age 74.0 yr [interquartile range 68.0-80.0 yr], 132 196 [63.5%] male). Although SGLT2 inhibitor prescribing increased over time, from 7.0% to 20.1%, statin prescribing was initially 10-fold higher and later threefold higher than SGLT2 inhibitor prescribing. In 2019/20, SGLT2 inhibitor prescribing was roughly 50% lower among those aged 75 years or older than among those younger than 75 years (12.9% v. 28.3%, p < 0.001) and in women than in men (15.3% v. 22.9%, p < 0.001). Age 75 years or older, female sex, history of heart failure and kidney disease, and low income were independent factors of lower SGLT2 inhibitor prescribing. Among physician specialists, visits to endocrinologists and family physicians were stronger factors of SGLT2 inhibitor prescribing than cardiologist visits.

Interpretation: We found that 1 in 5 patients with diabetes and atherosclerotic CVD were prescribed SGLT2 inhibitors in 2019/20, whereas statins were prescribed for 4 of every 5 patients. Although SGLT2 inhibitor prescribing increased over the study period, disparities in adoption by age, sex, socioeconomic status, comorbidities and physician specialty remained.