CMAJ open最新文献

Background: Endometriosis, a prevalent condition among females of reproductive age, may be associated with increased risk of cardiovascular disease (CVD) through chronic inflammation and early menopause. The objective of this study was to estimate the association between endometriosis and subsequent risk of CVD.

Methods: We conducted a population-based cohort study using administrative health data from Ontario residents from 1993 to 2015. We compared the incidence of CVD and cardiovascular health outcomes between females with endometriosis and 2 age-matched females without endometriosis. The primary outcome was hospital admission for CVD. Secondary outcomes included in-hospital CVD events of interest and emergency department visits for CVD. We used Cox proportional hazards models to estimate adjusted hazard ratios (HRs) between endometriosis and CVD events.

Results: We identified 166 835 eligible patients with endometriosis and matched 333 706 patients without endometriosis. The mean age of those with endometriosis was 36.4 years. Patients with endometriosis had a higher incidence of hospital admission for CVD (195 admissions/100 000 person-years) compared with those without endometriosis (163 admissions/100 000 person-years). Similarly, the incidence of secondary CVD events was slightly higher among patients with endometriosis (292 cases/100 000 person-years) than among those without endometriosis (224 cases/100 000 person-years). Females with endometriosis had an increased risk of hospital admission (adjusted HR 1.14, 95% confidence interval [CI] 1.10-1.19) and secondary CVD events (adjusted HR 1.26, 95% CI 1.23-1.30).

Interpretation: In this large, population-based study, endometriosis was associated with a small increased risk of CVD events. Future studies need to investigate potential etiological mechanisms and strategies to decrease long-term CVD risk in patients with endometriosis.

Background: Surgical program directors (PDs) play an integral role in the well-being and success of postgraduate trainees. Although studies about medical specialties have documented factors contributing to PD burnout, early attrition rates and contributory factors among surgical PDs have not yet been described. We aimed to evaluate Canadian surgical PD satisfaction, stressors in the role and areas institutions could target to improve PD support.

Methods: We administered a cross-sectional survey of postgraduate Canadian surgical PDs from all Royal College of Physicians and Surgeons of Canada accredited surgical specialties. Domains we assessed included PD demographics and compensation, availability of administrative support, satisfaction with the PD role and factors contributing to PD challenges and burnout.

Results: Sixty percent of eligible surgical PDs (81 out of 134) from all 12 surgical specialties responded to the survey. We found significant heterogeneity in PD tenure, compensation models and available administrative support. All respondents reported exceeding their weekly protected time for the PD position, and 66% received less than 0.8 full-time equivalent of administrative support. One-third of respondents were satisfied with overall compensation, whereas 43% were unhappy with compensatory models. Most respondents (70%) enjoyed many aspects of the PD role, including relationships with trainees and shaping the education of future surgeons. Significant stressors included insufficient administrative support, complexities in resident remediation and inadequate compensation, which contributed to 37% of PDs having considered leaving the post prematurely.

Interpretation: Most surgical PDs enjoyed the role. However, intersecting factors such as disproportionate time demands, lack of administrative support and inadequate compensation for the role contributed to significant stress and risk of early attrition.

Background: Comprehensive diagnostic imaging referral guidelines are an important tool to assist referring clinicians and radiologists in determining the safest and best-clinical-value diagnostic imaging study for their patients; the Canadian Association of Radiologists (CAR) last produced its diagnostic imaging referral guidelines in 2012. In partnership with several national organizations, referring clinicians, radiologists, and patient and family advisors from across Canada, the association is redoing its referral guidelines using a new methodology for guideline development, and these guideline recommendations will be suited for integration into clinical decision support systems.

Methods: Expert panels of radiologists, referring clinicians and a patient advisor will work with epidemiologists at the CAR to create guidelines across 13 clinical sections. The expert panel for each section will first create a comprehensive list of clinical and diagnostic scenarios to include in the guidelines. Canadian Association of Radiologists epidemiologists will then conduct a systematic rapid scoping review to identify systematically produced guidelines from other guideline groups. The corresponding expert panel will develop diagnostic imaging recommendations for each clinical and diagnostic scenario using the recommendations identified from the scoping review and contextualize them to the Canadian health care systems. The expert panels will accomplish this using an adapted Grading of Recommendations Assessment, Development and Evaluation framework, which reflects the benefits and harms, values and preferences, equity, accessibility, resources and cost.

Interpretation: Freely available, up-to-date, comprehensive Canadian-specific diagnostic imaging referral guidelines are needed. A transparent and structured guideline-development approach will aid the CAR and its partners in producing guidelines across its 13 sections.

Background: The COVID-19 pandemic has brought immense disruption worldwide, dramatically altering the ways we live, work and learn on a day-to-day basis; however, few studies have investigated this from the perspective of primary care providers. In this study, we sought to explore the experiences of primary care providers in the province of Nova Scotia, with the intention of understanding the impact of the COVID-19 pandemic on primary care providers' ability to provide care, their information pathways, and the personal and professional impact of the pandemic.

Methods: We conducted an exploratory qualitative research study involving semistructured interviews conducted via Zoom videoconferencing or telephone with primary care providers (physicians, nurse practitioners and family practice nurses) who self-identified as working in primary health care in Nova Scotia from June 2020 to April 2021. We performed a thematic analysis involving coding and classifying data according to themes. Emergent themes were then interpreted by seeking commonalties, divergence, relationships and overarching patterns in the data.

Results: Twenty-four primary care providers were interviewed. Subsequent analysis identified 4 interrelated themes within the data: disruption to work-life balance, disruptions to "non-COVID-19" patient care, impact of provincial and centralized policies, and filtering and processing an influx of information.

Interpretation: Our findings showed that managing a crisis of this magnitude requires coordination and new ways of working, balancing professional and personal life, and adapting to already implemented changes (i.e., virtual care). A specific primary care pandemic response plan is essential to mitigate the impact of future health care crises.

Background: Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits.

Methods: This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%).

Results: A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home.

Interpretation: A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.

Background: Assisted human reproduction (AHR) can be used to help individuals and couples overcome infertility issues. We sought to describe trends in pregnancies using AHR and to evaluate the impact of AHR on perinatal outcomes in a large population-based cohort in Alberta, Canada.

Methods: We linked maternal and child administrative data for all live births occurring July 1, 2009, to Dec. 31, 2018, in Alberta, Canada, for this retrospective study. We identified AHR pregnancies from pharmaceutical claims or codes from the International Classification of Diseases and Related Health Problems (9th or 10th revision). Our main outcome measures were the incidence and temporal trends of live births in AHR pregnancies. We also compared maternal characteristics and perinatal outcomes of AHR and non-AHR pregnancies, and by maternal age group.

Results: Of 518 293 live births during the study period, 26 270 (5.1%) were conceived with AHR. The incidence of AHR pregnancies increased from 30.8 per 1000 pregnancies in 2009 to 54.7 per 1000 pregnancies in 2018. Females who used AHR were older (33.9 yr v. 30.1 yr, p < 0.001) and the number of females aged 30-35 years and older than 35 years who delivered following AHR increased over the study period (30-35 yr: 36.9 to 55.3 per 1000 pregnancies; > 35 yr: 79.1 to 95.2 per 1000 pregnancies). The proportion of live births with cesarean delivery (40.5% v. 23.3%, p < 0.001), low birth weight (26.9% v. 7.6%, p < 0.001), congenital malformation (0.5% v. 0.3%, p = 0.002) and admission to the neonatal intensive care unit (25.3% v. 9.7%, p < 0.001) was higher in the AHR group than the non-AHR group.

Interpretation: The incidence of live births following AHR pregnancies in Alberta was 5.1% between 2009 and 2018, and increased by 0.26% per year; newborns in the AHR group appeared smaller and showed signs of poorer health. This study provides insights on potential perinatal complications following AHR that may be important when caring for the newborn child.

Background: Systematic guidance for considering health equity in guidelines is lacking. This scoping review aims to synthesize current best practices for integrating health equity into guideline development and the benefits or drawbacks of these practices.

Methods: We searched Ovid MEDLINE ALL and Embase Classic+Embase on the Ovid platform, CINAHL on EBSCO, and Web of Science (Core Collection) from 2010 to 2022. We searched grey literature from 2015 to 2022, using the Canadian Agency for Drugs and Technologies in Health Grey Matters checklist and searches of potentially relevant websites. Articles were screened independently by 1 reviewer. Proposed best practices, advantages and disadvantages, and tools were extracted independently by 1 reviewer and qualitatively synthesized based on the relevant steps of a comprehensive checklist covering the stages of guideline development.

Results: We included 26 articles that proposed best practices for incorporating health equity within the guideline development process. These practices were organized under different stages of the development process, including guideline planning, evidence review, guideline development and dissemination. Included studies provided best practices from guideline producers, articles discussing health equity in current guidelines, articles addressing strategies to increase equity in the guideline implementation process, and literature reviews of promising health equity practices.

Interpretation: Our scoping review identified best practices to incorporate health equity considerations at each phase of guideline development. Identified practices may be used to inform equity-promoting strategies with the guideline development process; however, guideline producers should carefully consider the advantages and disadvantages of best practices when integrating health equity.

Background: Postoperative pain management practices in breast surgery are variable, with recent evidence that approaches for minimizing or sparing opioids can be successfully implemented. We describe opioid filling and predictors of higher doses in patients undergoing same-day breast surgery in Ontario, Canada.

Methods: In this retrospective population-based cohort study, we used linked administrative health data to identify patients aged 18 years or older who underwent same-day breast surgery from 2012 to 2020. We categorized procedure types by increasing invasiveness of surgery: partial, with or without axillary intervention (P ± axilla); total, with or without axillary intervention (T ± axilla); radical, with or without axillary intervention (R ± axilla); and bilateral. The primary outcome was filling an opioid prescription within 7 or fewer days after surgery. Secondary outcomes were total oral morphine equivalents (OMEs) filled (mg, median and interquartile range [IQR]) and filling more than 1 prescription within 7 or fewer days after surgery. We estimated associations (adjusted risk ratios [RRs] and 95% confidence intervals [CIs]) between study variables and outcomes in multivariable models. We used a random intercept for each unique prescriber to account for provider-level clustering.

Results: Of the 84 369 patients who underwent same-day breast surgery, 72% (n = 60 620) filled an opioid prescription. Median OMEs filled increased with invasiveness (P ± axilla = 135 [IQR 90-180] mg; T ± axilla = 135 [IQR 100-200] mg; R ± axilla = 150 [IQR 113-225] mg, bilateral surgery = 150 [IQR 113-225] mg; p < 0.0001). Factors associated with filling more than 1 opioid prescription were age 30-59 years (v. age 18-29 yr), increased invasiveness (RR 1.98, 95% CI 1.70-2.30 bilateral v. P ± axilla), Charlson Comorbidity Index ≥ 2 versus 0-1 (RR 1.50, 95% CI 1.34-1.69) and malignancy (RR 1.39, 95% CI 1.26-1.53).

Interpretation: Most patients undergoing same-day breast surgery fill an opioid prescription within 7 days. Efforts are needed to identify patient groups where opioids may be successfully minimized or eliminated.

Background: Current methods used to estimate surgical wait times in Ontario may be subject to inconsistencies and inaccuracies. In this population-level study, we aimed to estimate cataract surgery wait times in Ontario using a novel, objective and data-driven method.

Methods: We identified adults who underwent cataract surgery between 2005 and 2019 in Ontario, using administrative records. Wait time 1 represented the number of days from referral to initial visit with the surgeon, and wait time 2 represented the number of days from the decision for surgery until the first eye surgery date. In the primary analysis, a ranking method prioritized referrals from optometrists, followed by ophthalmologists and family physicians.

Results: The cohort consisted of 1 138 532 people with mostly female patients (57.4%) and those aged 65 years and older (79.0%). In the primary analysis, the median was 67 days for wait time 1 (interquartile range [IQR] 29-147). There was a median of 77 days for wait time 2 (IQR 37-155). Overall, the following proportions of patients waited less than 3, 6 and 12 months: 54.1%, 78.5% and 91.7%, respectively. For wait time 2, the proportions of patients who waited less than 3, 6 and 12 months were 49.5%, 77.1% and 93.3%, respectively. In total, 19.3% of patients did not meet the provincial target for wait time 1, 20.5% did not meet the target for wait time 2 and 35.0% did not meet the target for wait times 1 or 2.

Interpretation: Administrative health services data can be used to estimate cataract surgery wait times. With this method, 35.0% of patients in 2005-2019 did not receive initial consultation or surgery within the provincial wait time target.

Background: There has been limited investigation of the unintended effects of routine screening for asymptomatic hypoglycemia in at-risk newborns. This study aimed to explore whether rates of exclusive breastfeeding were lower in screened babies than in unscreened babies.

Methods: This retrospective cohort study conducted in Ottawa, Canada, used data from Hôpital Montfort's electronic health information system. Healthy singleton newborns discharged between Feb. 1, 2014, and June 30, 2018, were included. We excluded babies and mothers with conditions expected to interfere with breastfeeding (e.g., twins). We investigated the association between postnatal screening for hypoglycemia and initial exclusive breastfeeding (in the first 24 hours of life).

Results: We included 10 965 newborns; of these, 1952 (17.8%) were fully screened for hypoglycemia. Of screened newborns, 30.6% exclusively breastfed and 64.6% took both formula and breastmilk in the first 24 hours of life. Of unscreened newborns, 45.4% exclusively breastfed and 49.8% received both formula and breastmilk. The adjusted odds ratio for exclusive breastfeeding in the first 24 hours of life among newborns screened for hypoglycemia was 0.57 (95% confidence interval 0.51-0.64).

Interpretation: The association of routine newborn hypoglycemia screening with a lower initial rate of exclusive breastfeeding suggests a potential effect of screening on early breastfeeding success. Confirmation of these findings might warrant a re-evaluation of the net benefit of asymptomatic postnatal hypoglycemia screening for different newborn populations at risk of hypoglycemia.