Open medicine : a peer-reviewed, independent, open-access journal最新文献

Background: Death or urgent readmission after hospital discharge is a common adverse event that can be used to compare outcomes of care between institutions. To accurately adjust for risk and to allow for interhospital comparisons of readmission rates, we used administrative data to derive and internally validate an extension of the LACE index, a previously validated index for 30-day death or urgent readmission.

Methods: We randomly selected 500 000 medical and surgical patients discharged to the community from any Ontario hospital between 1 April 2003 and 31 March 2009. We derived a logistic regression model on 250 000 randomly selected patients from this group and modified the final model into an index scoring system, the LACE+ index. We internally validated the LACE+ index using data from the remaining 250 000 patients and compared its performance with that of the original LACE index.

Results: Within 30 days of discharge to the community, 33 825 (6.8%) of the patients had died or had been urgently readmitted. In addition to the variables included in the LACE index (length of stay in hospital [L], acuity of admission [A], comorbidity [C] and emergency department utilization in the 6 months before admission [E]), the LACE+ index incorporated patient age and sex, teaching status of the discharge hospital, acute diagnoses and procedures performed during the index admission, number of days on alternative level of care during the index admission, and number of elective and urgent admissions to hospital in the year before the index admission. The LACE+ index was highly discriminative (C statistic 0.771, 95% confidence interval 0.767-0.775), was well calibrated across most of its range of scores and had a model performance that exceeded that of the LACE index.

Interpretation: The LACE+ index can be used to predict the risk of postdischarge death or urgent readmission on the basis of administrative data for the Ontario population. Its performance exceeds that of the LACE index, and it allows analysts to accurately estimate the risk of important postdischarge outcomes.

Background: Between 5% and 10% of patients die or are urgently readmitted within 30 days of discharge from hospital. Readmission risk indexes have either excluded acute diagnoses or modelled them as multiple distinct variables. In this study, we derived and validated a score summarizing the influence of acute hospital diagnoses and procedures on death or urgent readmission within 30 days.

Methods: From population-based hospital abstracts in Ontario, we randomly sampled 200 000 discharges between April 2003 and March 2009 and determined who had been readmitted urgently or died within 30 days of discharge. We used generalized estimating equation modelling, with a sample of 100 000 patients, to measure the adjusted association of various case-mix groups (CMGs-homogenous groups of acute care inpatients with similar clinical and resource-utilization characteristics) with 30-day death or urgent readmission. This final model was transformed into a scoring system that was validated in the remaining 100 000 patients.

Results: Patients in the derivation set belonged to 1 of 506 CMGs and had a 6.8% risk of 30-day death or urgent readmission. Forty-seven CMG codes (more than half of which were directly related to chronic diseases) were independently associated with this outcome, which led to a CMG score that ranged from -6 to 7 points. The CMG score was significantly associated with 30-day death or urgent readmission (unadjusted odds ratio for a 1-point increase in CMG score 1.52, 95% confidence interval [CI] 1.49-1.56). Alone, the CMG score was only moderately discriminative (C statistic 0.650, 95% CI 0.644-0.656). However, when the CMG score was added to a validated risk index for death or readmission, the C statistic increased to 0.759 (95% CI 0.753-0.765). The CMG score was well calibrated for 30-day death or readmission.

Interpretation: In this study, we developed a scoring system for acute hospital diagnoses and procedures that could be used as part of a risk-adjustment methodology for analyses of postdischarge outcomes.

In Canada, we place significant cultural and financial value on our healthcare system.  As such, it is imperative we measure its quality.  In this commentary, we highlight some of the potential benefits and harms associated with measuring quality using currently available indicators, such as hospital mortality rates, emergency department length of stays, and readmission rates.  These measures tend to focus on provider and process issues rather than patient outcomes and also reflect what we can measure rather than what we should measure.  We argue that the current approaches are inadequate and recommend a better understanding of the limitations of current indicators and more provider engagement.  To meet these recommendations the health system needs to increased investment in performance measurement systems.

Background: Metformin and a sulphonylurea are often used in combination for the treatment of type 2 diabetes mellitus. We conducted a systematic review and meta-analysis to evaluate the comparative safety and efficacy of all available classes of antihyperglycemic therapies in patients with type 2 diabetes inadequately controlled with metformin and sulphonylurea combination therapy.

Methods: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS Previews, PubMed and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials published in English from 1980 to November 2009. Additional citations were obtained from the grey literature and conference proceedings and through stakeholder feedback. Two reviewers independently selected the studies, extracted the data and assessed risk of bias. Key outcomes of interest were hemoglobin A1c, body weight, hypoglycemia, patients' satisfaction with treatment, quality of life, long-term diabetes-related complications, withdrawals due to adverse events, serious adverse events and mortality. Mixed-treatment comparison meta-analyses were conducted to calculate mean differences between drug classes for changes in hemoglobin A1c and body weight. When appropriate, pairwise meta-analyses were used to estimate differences for other outcomes.

Results: We identified 33 randomized controlled trials meeting the inclusion criteria. The methodologic quality of the studies was generally poor. Insulins (basal, biphasic, bolus), dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) analogues and thiazolidinediones (TZDs) all produced statistically significant reductions in hemoglobin A1c in combination with metformin and a sulphonylurea (-0.89% to -1.17%), whereas meglitinides and alpha-glucosidase inhibitors did not. Biphasic insulin, bolus insulin, and TZDs were associated with weight gain (1.85-5.00 kg), whereas DPP-4 inhibitors and alpha-glucosidase inhibitors were weight-neutral, and GLP-1 analogues were associated with modest weight loss. Treatment regimens containing insulin were associated with increased hypoglycemia relative to comparators, but severe hypoglycemia was rare across all treatments.

Interpretation: Third-line agents for the treatment of type 2 diabetes are similar in terms of glycemic control but differ in their propensity to cause weight gain and hypoglycemia. Longer-term studies with larger sample sizes are required to determine if any of the drug classes are superior with regard to reducing diabetes-related complications.

Background: Although effective treatments exist, many Canadians with chronic medical conditions do not receive the full care they require, possibly as a consequence of limited accessibility or availability. A commonly used indicator of inadequate access to or availability of care is the perception of unmet health care needs. The objective of this study was therefore to determine the association between chronic conditions and perceived unmet health care needs.

Methods: We extracted data for adult respondents from the combined 2001, 2003 and 2005 cross-sectional cycles of the Canadian Community Health Survey. Multivariate logistic regression was used to estimate the association between 7 high-prevalence and high-impact chronic conditions (arthritis, chronic obstructive pulmonary disease/emphysema, diabetes, heart disease, hypertension, mood disorder and stroke) and perceived unmet health care needs in the prior 12 months, adjusting for sociodemographic variables, health behaviours, health status and survey cycle.

Results: Of the 360 105 adult respondents, 12.2% reported an unmet health care need. Compared with those without chronic conditions, respondents with at least one condition were more likely to report an unmet need (adjusted odds ratio [OR] 1.51, 95% confidence interval [CI] 1.45-1.59). Those with mood disorders were almost twice as likely to report an unmet need (OR 1.94, 95% CI 1.78-2.12), while those with diabetes or hypertension were less likely to report an unmet need (diabetes OR 0.85, 95% CI 0.76-0.94; hypertension OR 0.96, 95% CI 0.89-1.04). Furthermore, the likelihood of an unmet need increased with the number of chronic conditions (OR 1.71, 95% CI 1.56-1.88 for 3 or more conditions). Respondents with chronic conditions were more likely than those without to report an unmet need related to resource availability (OR 1.14, 95% CI 1.06-1.22).

Interpretation: Adults with chronic medical conditions are more likely to report an unmet health care need, and the likelihood increases with an increasing number of conditions. Whether these unmet needs are associated with worse outcomes, and whether interventions targeted to address these needs may improve outcomes for Canadians with chronic disease, remain to be determined.

Background: Little information has been published on opioid prescribing practices in the United States as a whole for any year since 2005, despite increased use and increased overdoses. The objective of this study was to describe trends in prescribing rates and prescription sizes for commonly used opioids over the past decade.

Methods: We used 2 data systems. Vector One: National (VONA; data obtained for the period 2000-2009) is a service that can estimate the number of prescriptions dispensed by retail pharmacies. The Automation of Reports and Consolidated Orders System (ARCOS; data obtained for the period 2000-2010) is a mandatory reporting system that allows the US Drug Enforcement Administration to monitor certain controlled substances from the point of manufacture to the point of sale. ARCOS data represent the amount of controlled substances legitimately distributed at the retail level. We calculated crude prescription rates of various opioids from VONA data, total drug amounts distributed (as milligrams per 100 persons) from ARCOS data and morphine milligram equivalents (MME) per prescription by combining data from these 2 sources.

Results: The number of opioid prescriptions per 100 persons increased by 35.2%, from 61.9 to 83.7, during the period 2000-2009. The distribution of opioids to US pharmacies, in milligrams per 100 persons, increased by at least 100% for all selected opioids during the period 2000-2010. The average size of an oxycodone prescription increased by 69.7% (from 923 MME to 1566 MME) during the same period, while the average size of a hydrocodone prescription increased by 69.4% (from 170 MME to 288 MME). The increase for fentanyl was smaller (20.9%) (from 4804 MME to 5809 MME).

Interpretation: The rate of opioid prescribing, the amount of opioids distributed and the average prescription size all increased markedly in the United States over the past decade. Rates of death from opioid overdose also have increased steadily through 2008 and have likely continued to increase in subsequent years. Effective measures to prevent prescription drug overdoses have yet to be identified and employed.

Background: Although specialist physicians comprise nearly half of the physician workforce in Newfoundland and Labrador (NL), relatively little is known about their retention patterns. We compared 2 cohorts of physicians who were initially licensed to practise in NL between 1993 and 1997 and between 2000 and 2004, to examine whether retention had changed over time. Additionally, we examined the retention of 4 groups of physicians in each cohort: (1) fully licensed medical graduates of Memorial University, (2) fully licensed medical graduates of other Canadian universities, (3) provisionally licensed international medical graduates (IMGs) and (4) fully licensed IMGs. Provisional licences allow physicians who have not received Canadian certification to practise while obtaining credentials. We hypothesized that fully licensed physicians (largely physicians who are locally trained) would remain in NL longer than provisionally licensed physicians (largely IMGs).

Methods: Using data from the provincial medical registrar and Memorial University's office of postgraduate medical education, we used survival analysis (Cox regression) to compare the retention of the 2 cohorts and the 4 groups of physicians within each cohort.

Results: After 48 months, roughly 60% of the physicians in the 2000-04 cohort and 45% of the physicians in the 1993-97 cohort remained in NL. Medical graduates of Memorial University comprised 61/180 (33.9%) of the 2000-04 cohort and 38/211 (18.0%) of the 1993-97 cohort.Physicians in the 2000-04 cohort were 1.6 (95% confidence interval [CI] 1.23-2.08) times less likely to leave NL than physicians in the 1993-97 cohort. In the 2000-04 cohort, medical graduates of Canadian universities, provisionally licensed IMGs and fully licensed IMGs were 3.19 (95% CI 1.47-6.89), 1.85 (95% CI 1.09-3.17) and 4.39 (95% CI 1.91-10.10) times more likely to leave NL than medical graduates of Memorial University. In the 1993-97 cohort, IMGs with provisional licences were 2.16 (95% CI 1.37-3.42) times more likely to leave NL than medical graduates of Memorial University. There was no significant difference in retention between medical graduates of Memorial University and other Canadian universities or IMGs with full licences in the 1993-97 cohort.

Interpretation: The improvement in the retention of specialist physicians in NL since the 1990s may be attributable to the increase in the relative proportion of medical graduates of Memorial University. Although provisional licensing enables IMGs to begin practice in NL, it does not lead to long-term retention.