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Background: Commentaries on the adequacy of insurance coverage for prescription drugs available to Canadians have emphasized differences in the coverage provided by different provincial governments. Less is known about the actual financial burden of prescription drug spending and how this burden varies by province of residence, affluence and source of primary drug coverage.

Methods: We used data from a nationally representative household expenditure survey to analyze the financial burden of prescription drugs. We focused on the drug budget share (defined as the share of the household budget spent on prescription drugs), considering how it varied by province, total household budget and likely primary source of drug insurance coverage (i.e., provincial government plan for senior citizens, social assistance plan or private coverage). We examined both "typical" households (at the median of the distribution of the drug budget share) and households with relatively large shares (in the top 5%). Finally, we estimated the percentage of households with catastrophic drug expenditures (defined as a drug budget share of 10% or more) and the average catastrophic drug expenditures.

Results: Senior, social assistance and general population households accounted for 21.1%, 8.9% and 69.9% of the sample of 14,430 respondents to the 2006 Survey of Household Spending, respectively. The median drug budget share in Canada was 1.1% for senior households (range 0.4% [Ontario] to 3.6% [Saskatchewan]) and 0.1% for both social assistance households and general population households, with little appreciable variation across provinces for these latter 2 categories. The 95th percentile drug budget share in Canada was 7.4% for senior households (range 3.5% [Ontario] to 12.7% [Saskatchewan]), 5.4% for social assistance households (range 2.3% [British Columbia] to 13.0% [Prince Edward Island]) and 2.6% for general population households (range 2.1% [Ontario] to 5.4% [Prince Edward Island]). The interprovincial range of the 95th percentile drug budget share was 10.7 percentage points for social assistance households, 9.2 percentage points for senior households and 3.3 percentage points for general population households.

Interpretation: For most households, the financial burden of prescription drug expenditures appeared to be relatively small, with little interprovincial variation. However, a small number of households incurred catastrophic drug costs. These households were concentrated in the groups that traditionally benefit from provincial government drug plans. It is likely that some households did not purchase needed prescription drugs because of the expense, so our estimates of the financial burden of catastrophic prescription drug expenditures therefore represent a lower bound.

Background: Nursing homes provide long-term housing, support and nursing care to frail elders who are no longer able to function independently. Although studies conducted in the United States have demonstrated an association between for-profit ownership and inferior quality, relatively few Canadian studies have made performance comparisons with reference to type of ownership. Complaints are one proxy measure of performance in the nursing home setting. Our study goal was to determine whether there is an association between facility ownership and the frequency of nursing home complaints.

Methods: We analyzed publicly available data on complaints, regulatory measures, facility ownership and size for 604 facilities in Ontario over 1 year (2007/08) and 62 facilities in British Columbia (Fraser Health region) over 4 years (2004-2008). All analyses were carried out at the facility level. Negative binomial regression analysis was used to assess the association between type of facility ownership and frequency of complaints.

Results: The mean (standard deviation) number of verified/substantiated complaints per 100 beds per year in Ontario and Fraser Health was 0.45 (1.10) and 0.78 (1.63) respectively. Most complaints related to resident care. Complaints were more frequent in facilities with more citations, i.e., violations of the legislation or regulations governing a home, (Ontario) and inspection violations (Fraser Health). Compared with Ontario's for-profit chain facilities, adjusted incident rate ratios and 95% confidence intervals of verified complaints were 0.56 (0.27-1.16), 0.58 (0.34-1.00), 0.43 (0.21- 0.88), and 0.50 (0.30- 0.84) for for-profit single-site, non-profit, charitable, and public facilities respectively. In Fraser Health, the adjusted incident rate ratio of substantiated complaints in non-profit facilities compared with for-profit facilities was 0.18 (0.07-0.45).

Interpretation: Compared with for-profit chain facilities, non-profit, charitable and public facilities had significantly lower rates of complaints in Ontario. Likewise, in British Columbia's Fraser Health region, non-profit owned facilities had significantly lower rates of complaints compared with for-profit owned facilities.

Background: Practice pattern variations are often attributed to physician decision-making with no accounting for patient preferences.

Objective: To test whether a mass media television broadcast unrelated to health was associated with changes in the rate and characteristics of visits for acute emergency care.

Design: Time-series analysis of emergency department visits for any reason.

Subjects: Population-based sample of all patients seeking emergency care in Ontario, Canada.

Measures: The broadcast day was defined as the Olympic men's gold medal ice hockey game final. The control days were defined as the 6 Sundays before and after the broadcast day.

Results: A total of 99 447 visits occurred over the 7 Sundays, of which 13 990 occurred on the broadcast day. Comparing the broadcast day with control days, we found no significant difference in the hourly rate of visits before the broadcast (544 vs 537, p = 0.41) or after the broadcast (647 vs 639, p = 0.55). In contrast, we observed a significant reduction in hourly rate of visits during the broadcast (647 vs 783, p < 0.001), equal to an absolute decrease of 409 patients, a relative decrease of 17% (95% confidence interval 13-21), or about 136 fewer patients per hour. The relative decrease during the broadcast was particularly large for adult men with low triage severity. The greatest reductions were for patients with abdominal, musculoskeletal or traumatic disorders.

Conclusion: Mass media television broadcasts can influence patient preferences and thereby lead to a decrease in emergency department visits.

Background: An abdominal aortic aneurysm (AAA) that is identified when the abdomen is imaged for some other reason is known as an incidental AAA. No population-based studies have assessed the management of incidental AAAs. The objective of this study was to measure the completeness of radiographic monitoring of incidental AAAs by means of a population-based analysis.

Methods: We linked a cohort of patients with incidental AAA (defined as a previously unidentified aortic enlargement exceeding 30 mm in diameter found in an imaging study performed for another reason) to various population-based databases. We followed the patients to elective repair or rupture of the aneurysm, death or 31 Mar. 2009. We used evidence-based monitoring guidelines to calculate the proportion of observation time during which each incidental AAA was incompletely monitored. We used negative binomial regression to determine the association of patient-related factors with this outcome.

Results: For the period between January 1996 and September 2008, we identified 191 patients with incidental AAA (mean diameter 37.6 mm, 95% confidence interval [CI] 36.6-38.6 mm; median follow-up 4.4 [range 0.6-12.7] years). Fifty-six of these patients (29.3%) had no radiographic monitoring of the aneurysm. Overall, patients spent one-fifth of their time with incomplete monitoring of the AAA (median 19.4%, interquartile range 0.3%-44.0%). Factors independently associated with incomplete monitoring included older age (relative rate [change in proportion of time with incomplete monitoring] [RR] 1.27, 95% CI 1.10-1.47, per decade), larger size (RR 1.65, 95% CI 1.38-2.01, per 10-mm increase) and detection of the aneurysm while the patient was in hospital or the emergency department (RR 1.34, 95% CI 1.00-1.79). Comorbidities were not associated with monitoring.

Interpretation: Radiographic monitoring of incidental AAAs was incomplete, and almost one-third of patients underwent no monitoring at all. Incomplete monitoring did not appear to be related to patients' comorbidity.

Background: Opioid therapy for patients with chronic nonmalignant pain remains controversial, primarily because of safety concerns and the potential for abuse. The objective of this study was to examine trends in opioid utilization for nonmalignant pain among recipients of social assistance and to explore the relation between dose of analgesic and mortality.

Methods: Using a cross-sectional study design, we characterized annual trends in prescriptions for and daily dose of opioid analgesics between 2003 and 2008 for beneficiaries (aged 15 to 64 years) of Ontario's public drug plan. We defined moderate, high and very high dose thresholds as daily doses of up to 200, 201 to 400, and more than 400 mg oral morphine (or equivalent), respectively. In an exploratory cohort study, we followed, over a 2-year period, patients who received at least one prescription for an opioid in 2004 to investigate the relation between opioid dose and opioid-related mortality.

Results: Over the study period, opioid prescribing rates rose by 16.2%, and 180 974 individuals received nearly 1.5 million opioid prescriptions in 2008. Also by 2008, the daily dose dispensed exceeded 200 mg morphine equivalent for almost a third (32.6%) of recipients of long-acting oxycodone but only 20.3% of those treated with fentanyl or other long-acting opioids. Among patients for whom high or very high doses of opioids were dispensed in 2004, 19.3% of deaths during the subsequent 2 years were opioid-related, occurring at a median age of 46 years. Two-year opioid-related mortality rates were 1.63 per 1000 population (95% confidence interval [CI] 1.42-1.85) among people with moderate-dose prescriptions, 7.92 per 1000 population (95% CI 5.25-11.49) among those with high-dose prescriptions, and 9.94 per 1000 population (95% CI 2.78-25.12) among those with very-high-dose prescriptions.

Interpretation: Among socio-economically disadvantaged patients in Ontario, the use and dose of opioids for nonmalignant pain has increased substantially, driven primarily by the use of long-acting oxycodone and, to a lesser extent, fentanyl. The findings of our exploratory study suggested a strong association between opioid-related mortality and the dose of opioid dispensed.

Background: Composite outcomes that weight each component equally are commonly used to study treatment effects. We hypothesized that each component of a composite outcome would differentially affect patients' overall health-related quality of life (HRQL).

Methods: We tested our hypothesis using data from 2 published clinical studies of treatment for heart failure, one comparing metformin and sulfonylurea and the other comparing digoxin and placebo. We applied the quality-adjusted survival (QAS) approach, which incorporates HRQL data to accommodate differential weights for 2 components (in this analysis, death or admission to hospital) of a commonly used composite end point. For each of the 2 studies, the composite outcome was partitioned into its components, to which utility weights derived from the literature were assigned. Total QAS time determined for each treatment by the QAS analysis was compared with the results from traditional survival analyses based on Cox proportional hazards regression.

Results: In the observational study of metformin in heart failure, the risk of the composite outcome of death or admission to hospital was lower for those receiving metformin therapy than for those who received sulfonylurea (event rate 160 [77%] v. 658 [85%]; hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.70-0.99). With traditional survival analysis, the net gain was 0.82 years (95% CI 0.26-1.37), whereas the difference in QAS time was less, at 0.54 years (95% CI 0.20-0.89). In the randomized trial of digoxin therapy, the risk of the composite outcome was lower for those receiving the intervention than for those receiving placebo (event rate 1291 [38%] v. 1041 [31%]; HR 0.75, 95% CI 0.69-0.82). With traditional survival analysis, the net gain was 0.06 years (95% CI 0.02-0.16), whereas the difference in QAS time was greater, at 0.11 years (95% CI 0.06-0.16).

Interpretation: Studies that assume equal weights for the components of composite outcomes may overestimate or underestimate treatment effects. By incorporating HRQL into survival analyses, the impact of the various components of the outcome can be assessed more directly.