To assess the risk of systemic adverse events associated with intravitreal injections of vascular endothelial growth factor inhibiting drugs.
Population based nested case-control study.
91,378 older adults with a history of physician diagnosed retinal disease identified between 1 April 2006 and 31 March 2011. Cases were 1477 patients admitted to hospital for ischaemic stroke, 2229 admitted for an acute myocardial infarction, 1059 admitted or assessed in an emergency department for venous thromboembolism, and 2623 admitted for congestive heart failure. Event-free controls (at a ratio of 5:1) were matched to cases on the basis of year of birth, sex, history of the outcome in the previous 5 years, and diabetes.
Exposure to vascular endothelial growth factor inhibiting drugs identified within 180 days before the index date.
After adjustment for potential confounders, participants who had ischaemic stroke, acute myocardial infarction, congestive heart failure, or venous thromboembolism were not more likely than control participants to have been exposed to either bevacizumab (adjusted odds ratios of 0.95 (95% confidence interval 0.68 to 1.34) for ischaemic stroke, 1.04 (0.77 to 1.39) for acute myocardial infarction, 0.81 (0.49 to 1.34) for venous thromboembolism, and 1.21 (0.91 to 1.62) for congestive heart failure) or ranibizumab (adjusted odds ratios 0.87 (0.68 to 1.10) for ischaemic stroke, 0.90 (0.72 to 1.11) for acute myocardial infarction, 0.88 (0.67 to 1.16) for venous thromboembolism, and 0.87 (0.70 to 1.07) for congestive heart failure). Similarly, a secondary analysis of exclusive users of bevacizumab or ranibizumab showed no differences in risk between the two drugs (adjusted odds ratios for bevacizumab relative to ranibizumab of 1.03 (0.67 to 1.60) for ischaemic stroke, 1.23 (0.85 to 1.77) for acute myocardial infarction, 0.92 (0.51 to 1.69) for venous thromboembolism, and 1.35 (0.93 to 1.95) for congestive heart failure). These findings were consistent for all but one outcome in subgroup analyses.
Intravitreal injections of bevacizumab and ranibizumab were not associated with significant risks of ischaemic stroke, acute myocardial infarction, congestive heart failure, or venous thromboembolism.
Cites: Am J Ophthalmol. 2004 Mar;137(3):486-9515013873
Evaluation and optimization of antibiotic use (antibiotic stewardship) is being increasingly promoted as a means to reduce antibiotic resistance, adverse events, treatment complications and costs within institutions. Our goal was to examine the prevalence of antibiotic use among long-term care facility residents and the extent of variability across these institutions.
We conducted a population-based, point-prevalence study of antibiotic use among elderly individuals (n = 37,371) residing in long-term care facilities (n = 363 institutions) in Ontario between April and June 2009, using linked healthcare databases from Canada's largest province. Facilities were grouped into quintiles according to their mean antibiotic dispensing rates and variation was compared across quintiles.
There were 2190 (5.9%) long-term care residents receiving antibiotic prescriptions on the study date. The three most prevalent antibiotics were agents most commonly used for the treatment of urinary tract infections, including nitrofurantoin (365, 15.4%), trimethoprim/sulfamethoxazole (338, 14.3%) and ciprofloxacin (304, 12.8%). The majority of treatment courses were at least 10 days in duration (1482, 62.6%), and many exceeded 90 days (495, 20.9%), suggesting chronic prophylaxis. There was substantial variability in antibiotic use across facilities, with a 5-fold variation from the highest-use quintile (10.8%) to the lowest-use quintile (2.2%). This variation persisted after adjustment for multiple facility-level and resident-level factors, including demographic characteristics, healthcare utilization statistics, co-morbidity prevalence, functional status and device dependence.
Antibiotic use is common among long-term care residents, variable across institutions, and may benefit from focused antimicrobial stewardship interventions to standardize treatment indications and duration.
Antipsychotic drugs are widely used to manage behavioral and psychological symptoms in dementia despite concerns about their safety.
To examine the association between treatment with antipsychotics (both conventional and atypical) and all-cause mortality.
Population-based, retrospective cohort study.
Older adults with dementia who were followed between 1 April 1997 and 31 March 2003.
The risk for death was determined at 30, 60, 120, and 180 days after the initial dispensing of antipsychotic medication. Two pairwise comparisons were made: atypical versus no antipsychotic use and conventional versus atypical antipsychotic use. Groups were stratified by place of residence (community or long-term care). Propensity score matching was used to adjust for differences in baseline health status.
A total of 27,259 matched pairs were identified. New use of atypical antipsychotics was associated with a statistically significant increase in the risk for death at 30 days compared with nonuse in both the community-dwelling cohort (adjusted hazard ratio, 1.31 [95% CI, 1.02 to 1.70]; absolute risk difference, 0.2 percentage point) and the long-term care cohort (adjusted hazard ratio, 1.55 [CI, 1.15 to 2.07]; absolute risk difference, 1.2 percentage points). Excess risk seemed to persist to 180 days, but unequal rates of censoring over time may have affected these results. Relative to atypical antipsychotic use, conventional antipsychotic use was associated with a higher risk for death at all time points. Sensitivity analysis revealed that unmeasured confounders that increase the risk for death could diminish or eliminate the observed associations.
Information on causes of death was not available. Many patients did not continue their initial treatments after 1 month of therapy. Unmeasured confounders could affect associations.
Atypical antipsychotic use is associated with an increased risk for death compared with nonuse among older adults with dementia. The risk for death may be greater with conventional antipsychotics than with atypical antipsychotics.
Comment In: Evid Based Ment Health. 2008 May;11(2):5418441143
SummaryForPatientsIn: Ann Intern Med. 2007 Jun 5;146(11):I5217548405
Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
To better understand how centenarians use the healthcare system as an important step toward improving their service delivery.
Population-based retrospective cohort study using linked health administrative data.
Ontario--Canada's largest province.
All individuals living in Ontario aged 65 and older on April 1 of each year between 1995 and 2010 were identified and divided into three age groups (65-84, 85-99, = 100). A detailed description was obtained on 1,842 centenarians who were alive on April 1, 2010.
Sociodemographic characteristics and use of health services.
The number of centenarians increased from 1,069 in 1995 to 1,842 in 2010 (72.3%); 6.7% were aged 105 and older. Over the same period, the number of individuals aged 85 to 99 grew from 119,955 to 227,703 (89.8%). Women represented 85.3% of all centenarians and 89.4% of those aged 105 and older. Almost half of centenarians lived in the community (20.0% independently, 25.3% with publicly funded home care). Preventive drug therapies (bisphosphonates and statins) were frequently dispensed. In the preceding year, 18.2% were hospitalized and 26.6% were seen in an emergency department. More than 95% saw a primary care provider, and 5.3% saw a geriatrician.
The number of centenarians in Ontario increased by more than 70% over the last 15 years, with even greater growth among older people who could soon become centenarians. Almost half of centenarians live in the community, most are women, and almost all receive care from a primary care physician.
Use of multiple, concurrent drug therapies, often referred to as polypharmacy, is a concern in the long term care (LTC) setting, where frail older adults are particularly at risk for adverse events. We quantified the scope of this practice by exploring variation in the use of nine or more drug therapies across LTC homes.
Cross-sectional analysis of LTC home census data.
All LTC homes in Ontario, Canada.
A total of 64,394 LTC residents aged 66 years and older residing in 589 LTC homes in the fall of 2005.
Facility-level rates of polypharmacy were compared with rates of use of Beers criteria and antipsychotic drug therapies. Multivariate logistic regression models were used to assess predictors of polypharmacy across residents and LTC homes.
Nine or more drug therapies were dispensed concurrently to 10,007 (15.5%) of LTC home residents. Compared with those dispensed fewer drugs, residents receiving 9 or more drug therapies were more likely to have multiple comorbidities. There was threefold variation in polypharmacy rates across homes (26.2% versus 7.9%) and facility-level rates of polypharmacy were modestly correlated with rates of use of Beers criteria drugs (r = 0.27, P
To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies.
Cross-sectional study involving a 2005 province-wide census of LTC residents' charts linked to additional health care administrative databases.
All LTC homes in Ontario.
Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care.
Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns.
The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P
Cites: CMAJ. 2002 Feb 19;166(4):429-3411876170
Cites: Am J Med. 2000 Aug 1;109(2):87-9410967148
Cites: J Am Med Dir Assoc. 2003 May-Jun;4(3):145-5112854988
Cites: J Am Geriatr Soc. 1993 Apr;41(4):454-88463535
Cites: J Am Geriatr Soc. 1997 Aug;45(8):911-79256840
Cites: Arch Intern Med. 2005 Jan 10;165(1):68-7415642877
Cites: J Am Geriatr Soc. 2005 Oct;53(10):1826-816181186
Cites: J Am Med Dir Assoc. 2006 Jul;7(6):394-7; discussion 397-816843242
Cites: Can Fam Physician. 2006 Jun;52:752-317273484
Cites: Health Serv Res. 2007 Aug;42(4):1783-9617610448
Cites: J Am Med Dir Assoc. 2007 Nov;8(9):558-6717998111
Cites: Arch Intern Med. 2010 Jan 11;170(1):89-9520065204
Cites: Can Fam Physician. 2010 Jan;56(1):e30-520090058
Cites: Arch Intern Med. 2010 Mar 8;170(5):407-920212175
Cites: Am Fam Physician. 2010 May 15;81(10):120020507043
Cites: Am J Geriatr Psychiatry. 2010 Dec;18(12):1078-9220808119
Cites: Health Serv Res. 2002 Oct;37(5):1159-8012479491
Cites: J Am Geriatr Soc. 2002 May;50(5):949-5512028186
Cites: BMJ. 1999 Oct 16;319(7216):1062-310576847
Erratum In: Can Fam Physician. 2012 Dec;58(12):1335
To obtain population-based estimates of emergency department (ED) visits by long-term care (LTC) residents.
Retrospective cohort study using administrative data.
All LTC facilities in Ontario, Canada.
All LTC residents who visited an ED at least once during a 6-month period.
All ED visits were described using the National Ambulatory Care Reporting System. Two distinct visit types were defined. Potentially preventable visits were defined as those for any ambulatory care sensitive condition; these are conditions for which exacerbations that result in hospital use suggest lack of access to adequate primary care. Low-acuity visits were defined as those triaged as non-urgent at ED registration and ended with return to the LTC facility without hospital admission.
Nearly one-quarter of LTC residents visited the ED at least once in 6 months. Of all visits, 24.6% were for a potentially preventable reason, most commonly pneumonia, urinary tract infection, and congestive heart failure. These visits had a high frequency of ambulance transport (90.4%), emergent triage (35.3%), hospital admission (62.4%), and death within 30 days (23.6%). Of all visits, 11.0% were low acuity. Fall-related injury was the most common cause. Low-acuity visits were the shortest (mean length 4.5 +/- 4.0 hours) and had the lowest frequency of death within 30 days (4.3%).
LTC residents made frequent visits to the ED. The visit types showed distinct patterns that suggest a need for better access to medical care for common conditions and a greater emphasis on fall prevention in LTC.
Home care is integral to enabling older adults to delay or avoid long-term care (LTC) admission. To date, there is little population-based data about gender differences in home care users and their subsequent outcomes. Our objectives were to quantify differences between women and men who used home care in Ontario, Canada and to determine if there were subsequent differences in LTC admission.
This is a population-based retrospective cohort study. We identified all adults aged 76+ years living in Ontario and receiving home care on April 1, 2007 (baseline). Using the Resident Assessment Instrument - Home Care (RAI-HC) linked to other databases, we characterized the cohort by living condition, health and functioning, and identified all acute care and LTC use in the year following baseline.
The cohort consisted of 51,201 women and 20,102 men. Women were older, more likely to live alone, and more likely to rely on a child or child-in-law for caregiver support. Men most frequently identified a spouse as caregiver and their caregivers reported distress twice as often as women's caregivers. Men had higher rates of most chronic conditions and were more likely to experience impairment. Men were more likely to be admitted to hospital, to have longer stays in hospital, and to be admitted to LTC.
Understanding who uses home care and why is critical to ensuring that these programs effectively reduce LTC use. We found that women outnumbered men but that men presented with higher levels of need. This detailed gender analysis highlights how needs differ between older women, men, and their respective caregivers.
Cites: Can J Aging. 2011 Sep;30(3):371-9021851753
Cites: Med Care. 2008 Apr;46(4):380-718362817
Cites: Can J Public Health. 2001 Mar-Apr;92(2):155-911338156
Cites: Am J Epidemiol. 2001 Nov 1;154(9):854-6411682368
In an effort to improve efficiency and quality of care, regionalization of adult critical care services, similar to trauma and neonatal intensive care, has been suggested. However, there is little research to understand if hospitals with higher patient volumes have better outcomes. Our objective is to determine whether hospital volume is associated with improved survival for medical or surgical patients receiving mechanical ventilation.
Population-based retrospective cohort study.
Province of Ontario, Canada.
A total of 13,846 medical and 6,373 surgical patients receiving mechanical ventilation for greater than two consecutive days between 1998 and 2000.
Odds ratio for death within 30 days of initiation of mechanical ventilation was calculated in relation to hospital volume of ventilation. Estimates were adjusted for patient demographics, diagnoses, and urgency status; hospital region and rural location; and accounted for clustering within hospitals.
There was no effect of volume on mortality for surgical patients. After adjustment for clustering, among medical patients, the lowest-volume category ( or =700 episodes/yr). A post hoc analysis revealed that within the lowest-volume category, the proportion of patients transferred to larger hospitals was 81% for hospitals with 2 days, hospital volume had no effect on mortality. For medical patients, higher mortality may occur in a subgroup of low-volume hospitals that do not routinely transfer their patients to larger-volume facilities. This finding needs further investigation in a larger-sized study.
Comment On: Crit Care Med. 2006 Sep;34(9):2495-716921324