Wait times for cancer surgery in Ontario have increased over the last decade. We reviewed trends in wait times for endometrial cancer surgery from 1996 to 2000 and identified determinants that may need to be addressed in order to reduce these wait times.
The study population included women diagnosed with endometrial cancer (ICD-9 codes 179 or 182) prior to surgery. Surgical wait time was defined as the interval between date of diagnosis and hospital admission for surgery. Univariate analyses assessed demographic, treatment, and hospital factors associated with wait times. A multilevel linear regression model was created to account for clustering of patients at the hospital level and regional level defined by local health integration networks (LHINs). Effects of covariates were expressed as estimates of the median proportional change in wait time.
There were 2042 cases in this analysis. Mean wait time increased from 32 to 40 days (P = 0.0012). Prolonged wait times were associated with age > 70 years, presence of comorbidities, and surgery performed at a teaching hospital and by a gynaecologic oncologist. Wait times were not associated with income level or region of residence defined by LHIN.
Wait times for endometrial cancer surgery have increased significantly in Ontario. Determinants of these prolonged wait times need to be addressed, and criteria for referral to a teaching hospital and gynaecologic oncologist should be developed to ensure that local health integration networks provide equal and timely access to care.
Canada has a single-payer, publicly-funded health care system that provides comprehensive health care, and therefore significant disparities in health outcomes are not expected in our population. The objective of this study was to determine if differences exist in endometrial cancer outcomes across regions in Ontario.
This was a population-based study of all endometrial (uterine) cancer cases diagnosed from 1996 to 2000 in Ontario and linked to various administrative databases. Univariate analyses examined trends in demographics (age, income, co-morbidities), treatment (surgical staging and adjuvant pelvic radiotherapy), and pathology (grade, histology, stage) across 14 geographic regions defined by local health integration networks (LHINs) in Ontario. Primary outcome was 5-year overall survival among LHINs, which were compared in a multilevel Cox regression model to account for clustering of patient data at the hospital level.
There were 3,875 evaluable cases with complete information on demographics, treatment, pathology, and outcomes. There was significant variation in patient demographics, treatment, and pathology across the 14 LHINs. Low income level and surgery at a low-volume, community hospital without gynecologic oncologists were not associated with a higher risk of death. There was a trend towards clustering of patients within hospitals. After adjustment for covariates, there was no significant difference in survival across LHINs.
In the context of a single-payer, publicly-funded health care system, we did not find significant regional differences in endometrial cancer outcomes.
The purpose of this study was to describe (1) the aggressiveness of care in a population of patients who die of lung cancer and (2) differences in care between a sample of lung cancer patients who died in an acute care hospital (DH) and a sample of lung cancer patients who were admitted to hospital during the last six months of life but were discharged and died elsewhere (DO). All lung cancer deaths in 2002 were identified in the provincial registry. Cases were linked to administrative sources of health care data to describe the population as a whole and the aggressiveness of the care that they received. Primary data were collected from a province-wide sample of patients' hospital charts focusing on reasons for admission, care in hospital, advanced planning, pain, and disposition. In total, 5,855 patients who died of lung cancer in 2002 were eligible for inclusion in the cohort. Rates of in-hospital death, emergency room visits, intensive care unit admissions, and chemotherapy use near the end of life were 59.5%, 32.2%, 5.5%, and 4.6%, respectively. The records of 491 patients were abstracted for this study. The DH and DO groups were similar with respect to age, gender, neighborhood income level, and extent of metastatic disease. The most common chief complaints were shortness of breath, pain, inability to cope at home, and altered level of consciousness. Compared to patients in the DO group, those in the DH group presented with pain more often (19% vs. 10%, P
High and variable rates of injury have been reported in Aboriginal communities in Canada. This has not been well studied for specific injury types. We sought to compare the rate and categories of injuries leading to hospital admission among those in First Nations communities relative to those living in small northern and southern communities in Ontario.
Administrative data were used to define the study populations. The incidence of all-cause injury and specific injury categories for residents living in Ontario's Aboriginal communities (N = 28,816) was determined for 2004 using hospital discharge data. Comparisons were made with residents of small communities in northern (N = 211,834) and southern Ontario (N = 650,002). Age- and sex-adjusted rates were calculated.
All-cause-injury age- and sex-adjusted rates were 2.5 times higher for those living in First Nations communities compared to those living in northern communities. Relative risks (RR) for specific injury types in First Nations compared with northern communities were: assault (RR = 5.5 in females and 4.8 in males), intentional self-harm (RR = 5.9 in females and 5.2 in males) and accidental poisoning (RR = 4.9 in females and 3.7 in males). Differences were also seen between northern and southern communities: assault (RR = 2.8 in females and 3.5 in males), intentional self-harm (RR = 2.1 in females and 1.4 in males) and accidental poisoning (RR = 2.2 in females and 1.7 in males).
Injuries severe enough to require a hospital admission were higher in First Nations communities in northern Ontario relative to those in northern and southern Ontario communities. Higher rates of certain injuries were also noted in northern compared with southern communities. This underscores the importance of using a geographic comparison group.
Comment In: Can J Public Health. 2009 Jul-Aug;100(4):24419722333
An understanding of the life expectancy of patients with heart failure (HF) may assist in difficult treatment decisions such as placement of an implantable cardioverter-defibrillator or initiation of end-of-life care. However, previous studies have focused on predicting shorter-term mortality and limited data currently exist to predict expected survival among hospitalized patients with HF.
We studied 9943 patients who were newly hospitalized with HF between 1999 and 2001 in Ontario, Canada. Median survival was calculated using survival analysis and stratified by baseline characteristics and the EFFECT HF risk score. These analyses were repeated for the 1467 patients who had left ventricular ejection fraction of
Comment In: Am Heart J. 2008 Feb;155(2):195-618215585
In 1999, a series of clinical trials along with a clinical announcement from the National Cancer Institute (NCI) suggested that chemotherapy should be used concurrently with pelvic radiation in the management of cervical cancer. The purpose of this study is to examine the rate of chemotherapy use, in the province of Ontario, before and after these publications.
All incident cases of cervix cancer diagnosed between January 1, 1995, and March 31, 2001, were identified using the provincial cancer registry. These records were electronically linked to billing claims data and inpatient discharge abstract data. Patients receiving brachytherapy within 6 months of diagnosis were identified. The proportion receiving at least one injection of chemotherapy before brachytherapy was identified and compared in the "pre" and "post" publication group (April 1, 1999, cutoff).
We identified 1039 cases as receiving curative radiation. In the pre cohort, 9.4% of patients received chemotherapy (95% CI, 7.3-11.4%) vs. 67.4% in the post cohort (95% CI, 61.8-73.0%). The change occurred abruptly in the first quarter of 1999.
There was a significant increase in chemotherapy use after the publication of the NCI alert and related trials. Reasons for rapid uptake are discussed.
Discrepancies may exist between an original pathology report and formal pathology review, with subsequent implications for treatment. We conducted a study of pathology review in endometrial cancer from a population-based study to identify areas of discrepancy and effect on treatment.
This was a retrospective cohort study in Ontario, Canada from 1996 to 2000. We identified hysterectomy cases from patients with endometrial cancer that were subject to formal pathology review by a gynecologic pathologist at one of six tertiary care centers. Sarcomas and other rare histologic subtypes with fewer than five cases were excluded. We evaluated discrepancy between original pathology and review by demographics, stage, grade, and risk group. Four risk groups were defined: 1) low (stage I), 2) intermediate (stage I and II), 3) high-risk (stage I and II), and 4) advanced stage (all stage III and IV). Reclassification from one risk group to another upon pathology review represented a potential change in treatment. Factors associated with significant discrepancy were identified by a multivariable logistic regression model.
Formal pathology review was available on 450 cases. There were no differences by age, year, or hospital type. The overall discrepancy rate was 42.7% (95% confidence interval 38.2-47.3%). The intermediate-risk group had the highest rate of reclassification into another group (33.1%). The most significant rates of discrepancy were associated with endometrioid grades 2 and 3 tumors and stage IIA disease (39.8%, 50.9%, and 79.6%, respectively).
There was significant discrepancy between original pathology and formal review in endometrial cancer, with implications for guidelines on pathology review at a population level.