Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study

BACKGROUND:Little is known about the risk of death among people who visit emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. Our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, Canada.METHODS:We conducted a population-based retrospective cohort study using linked health administrative data (Jan. 1, 2010, to Dec. 31, 2016) in Ontario for people aged 16–105 years who made at least 2 emergency department visits for mental or behavioural disorders due to alcohol within 1 year. We subdivided the cohort based on visit frequency (2, 3 or 4, or ≥ 5). The primary outcome was 1-year mortality, adjusted for age, sex, income, rural residence and presence of comorbidities. We examined premature mortality using years of potential life lost (YPLL).RESULTS:Of the 25 813 people included in the cohort, 17 020 (65.9%) had 2 emergency department visits within 1 year, 5704 (22.1%) had 3 or 4 visits, and 3089 (12.0%) had 5 or more visits. Males, people aged 45–64 years, and those living in urban centres and lower-income neighbourhoods were more likely to have 3 or 4 visits, or 5 or more visits. The all-cause 1-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The adjusted mortality rate was 38% higher for patients with 5 or more visits than for those with 2 visits (adjusted hazard ratio 1.38, 95% confidence interval 1.19–1.59). Among 25 298 people aged 16–74 years, this represented 30 607 YPLL.INTERPRETATION:We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.

Alcohol is a leading driver of morbidity and mortality worldwide.¹ An estimated 3 million deaths in 2016 — 5% of all global deaths — were attributable to alcohol consumption.² The 2016 Global Burden of Disease Study showed that alcohol was the single greatest risk factor for ill health worldwide among people aged 15–49 years.³ In Canada, hospital admissions for alcohol-attributable conditions out-number those for myocardial infarction.⁴ Alcohol-related harms cost Canadians about $14.6 billion annually, with $3.3 billion in health care costs.⁵In addition to the societal impact of mental and behavioural disorders due to alcohol (henceforth referred to as alcohol-related) — mainly acute intoxication and withdrawal — these disorders are common reasons for emergency department visits.^6,7 Data from the United States and Canada, furthermore, suggest that alcohol-related emergency department visits have increased in recent years.^8,9 For example, a study in Ontario showed that, between 2003 and 2016, the age-standardized rates of alcohol-attributable emergency department visits increased by 86.5% in women and 53.2% in men.⁸ People who visit emergency departments frequently for alcohol-related reasons have high levels of comorbidity and social disadvantage,^10,11 and represent a readily identifiable patient population for whom interventions to address unmet social and health care needs could be developed.^12–14 A systematic review suggested that screening and brief intervention for alcohol-related problems in the emergency department is a promising approach for reducing problematic alcohol consumption.¹³Despite this, little is known about the risk of death, a key outcome for health system performance, among people who use emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. To address this gap, our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, the most populous Canadian province.¹⁵     

Predictors of death among patients who completed tuberculosis treatment: a population-based cohort study

Background

Mortality among patients who complete tuberculosis (TB) treatment is still high among vulnerable populations. The objective of the study was to identify the probability of death and its predictive factors in a cohort of successfully treated TB patients.

Methods

A population-based retrospective longitudinal study was performed in Barcelona, Spain. All patients who successfully completed TB treatment with culture-confirmation and available drug susceptibility testing between 1995–1997 were retrospectively followed-up until December 31, 2005 by the Barcelona TB Control Program. Socio-demographic, clinical, microbiological and treatment variables were examined. Mortality, TB Program and AIDS registries were reviewed. Kaplan-Meier and a Cox regression methods with time-dependent covariates were used for the survival analysis, calculating the hazard ratio (HR) with 95% confidence intervals (CI).

Results

Among the 762 included patients, the median age was 36 years, 520 (68.2%) were male, 178 (23.4%) HIV-infected, and 208 (27.3%) were alcohol abusers. Of the 134 (17.6%) injecting drug users (IDU), 123 (91.8%) were HIV-infected. A total of 30 (3.9%) recurrences and 173 deaths (22.7%) occurred (mortality rate: 3.4/100 person-years of follow-up). The predictors of death were: age between 41–60 years old (HR: 3.5; CI:2.1–5.7), age greater than 60 years (HR: 14.6; CI:8.9–24), alcohol abuse (HR: 1.7; CI:1.2–2.4) and HIV-infected IDU (HR: 7.9; CI:4.7–13.3).

Conclusions

The mortality rate among TB patients who completed treatment is associated with vulnerable populations such as the elderly, alcohol abusers, and HIV-infected IDU. We therefore need to fight against poverty, and promote and develop interventions and social policies directed towards these populations to improve their survival.     

Factors predicting patient use of the emergency department: a retrospective cohort study

Background:

Many studies have shown the tendency for people without a regular care provider or primary physician to make greater use of emergency departments. We sought to determine the effects of three aspects of care provided by primary physicians (physician specialty, continuity of care and comprehensiveness of care) on their patients’ use of the emergency department.

Methods:

Using provincial administrative databases, we created a cohort of 367 315 adults aged 18 years and older. Participants were residents of urban areas of Quebec. Affiliation with a primary physician, the specialty of this physician (i.e., family physician v. specialist), continuity of care (as measured using the Usual Provider Continuity index) and comprehensiveness of care (i.e., number of complete annual examinations) were measured among participants (n = 311 701) who had visited a physician three or more times during a two-year baseline period. We used multivariable negative binomial regression to investigate the relationships between measures of care and the number of visits to emergency departments during a 12-month follow-up period.

Results:

Among participants under 65 years of age, emergency department use was higher for those not affiliated than for those affiliated with a family physician (incidence rate ratio [IRR] 1.11, 95% confidence interval [CI] 1.05–1.16) or a specialist (IRR 1.10, 95% CI 1.04–1.17). Among patients aged 65 years and older, having a specialist primary physician, as opposed to a family physician, predicted increased use of the emergency department (IRR 1.13, 95% CI 1.09–1.17). Greater continuity of care with a family physician predicted less use of the emergency department only among participants who made 25 or more visits to a physician during the baseline period. Greater continuity of care with a specialist predicted less use of the emergency department overall, particularly among participants with intermediate numbers of multimorbidities and admissions to hospital. Greater comprehensiveness of care by family physicians predicted less use of the emergency department.

Interpretation:

Efforts to increase the proportion of adults affiliated with a family physician should target older adults, people who visit physicians more frequently and people with multiple comorbidities and admissions to hospital.Reforming primary care in Canada has been stimulated in part by increased crowding of emergency departments and evidence that their use, particularly for nonurgent care, may be related to inadequate primary care in the community.^1,2 Restructuring efforts, such as encouraging family physicians to work in multidisciplinary group practices with 24-hour access, are challenged by a relative shortage of family physicians.³ These issues are of particular importance in Quebec; despite relatively high numbers of family physicians per capita, in comparison with other provinces, residents of Quebec have the lowest rates of affiliation with a family physician and have one of the highest rates of seeing specialists.^4,5 In addition, residents of Quebec have among the highest rates of visits to emergency departments in international comparative studies.^6–8Research is needed into the effect that affiliation with a specialist rather than a family physician has on patients’ use of the emergency department, as is research into the continuity and comprehensiveness of care provided by the primary physician, regardless of specialty.Many studies have shown the tendency for people without a regular care provider to use the emergency department more often than people who have a primary physician.^1,9,10 Greater continuity of care with a primary physician has also been associated with fewer visits to the emergency department, but much of this research is cross-sectional, making causal interpretation difficult.¹¹ Furthermore, the distinction between continuity with a family physician versus a specialist primary physician has not been made, although one American study reported that having a specialist primary physician was associated with increased use of emergency departments.⁹We sought to determine whether certain factors predicted patients’ subsequent use of emergency departments, such as the specialty of their primary physician, the continuity of care with that physician and the comprehensiveness of care provided by that physician. To determine whether certain subgroups of the population may derive greater benefit from a particular type of care, we examined the potentially modifying effects of demographic factors, health status and previous use of health services. We restricted our study to residents of urban areas of Quebec for three reasons: rural residents visit the emergency department for primary care more often than residents of urban areas;¹² most specialist care is provided in urban areas; and primary care services in rural areas are more likely to be provided by salaried physicians, whose information is not available in the billing database.     

Risk of infection following a visit to the emergency department: a cohort study

Background:

The risk of infection following a visit to the emergency department is unknown. We explored this risk among elderly residents of long-term care facilities.

Methods:

We compared the rates of new respiratory and gastrointestinal infections among elderly residents aged 65 years and older of 22 long-term care facilities. We used standardized surveillance definitions. For each resident who visited the emergency department during the study period, we randomly selected two residents who did not visit the emergency department and matched them by facility unit, age and sex. We calculated the rates and proportions of new infections, and we used conditional logistic regression to adjust for potential confounding variables.

Results:

In total, we included 1269 residents of long-term care facilities, including 424 who visited the emergency department during the study. The baseline characteristics of residents who did or did not visit the emergency department were similar, except for underlying health status (visited the emergency department: mean Charlson Comorbidity Index 6.1, standard deviation [SD] 2.5; did not visit the emergency department: mean Charlson Comorbidity index 5.5, SD 2.7; p < 0.001) and the proportion who had visitors (visited the emergency department: 46.9%; did not visit the emergency department: 39.2%; p = 0.01). Overall, 21 (5.0%) residents who visited the emergency department and 17 (2.0%) who did not visit the emergency department acquired new infections. The incidence of new infections was 8.3/1000 patient-days among those who visited the emergency department and 3.4/1000 patient-days among those who did not visit the emergency department. The adjusted odds ratio for the risk of infection following a visit to the emergency department was 3.9 (95% confidence interval 1.4–10.8).

Interpretation:

A visit to the emergency department was associated with more than a threefold increased risk of acute infection among elderly people. Additional precautions should be considered for residents following a visit to the emergency department.Infections associated with health care are an important health risk. A recent survey by the World Health Organization reported that 8.7% of patients in hospital developed such infections.^1,2 The third leading cause of death in the United States is health care–associated deaths, with over 100 000 people dying from infections associated with health care each year.³ In Canada, a point-prevalence survey found that 11.6% of adults in hospital experience a health care–associated infection.⁴Little attention has been paid to infections acquired in other health care settings. Visiting an emergency department has been identified as a risk for disease during outbreaks of measles^5,6 and SARS,^7,8 but little is known about the potential risk of endemic infection from exposure in this setting. A visit to the emergency department differs from a stay in hospital: exposure and duration of contact with other patients is shorter, but the number and density of patients with acute illness with whom there could be contact is higher.Elderly residents of long-term care facilities are likely to be at the greatest risk of morbidity and mortality from communicable diseases acquired in the emergency department. When residents are transferred to the emergency department for assessment, they are likely to have longer stays and to be cared for in multibed observation areas and corridors.⁹ If they acquire an infection while in the emergency department, these residents may be the source of an outbreak upon return to their facility; this can lead to increases in workload and costs. A Canadian study estimated the cost of an influenza outbreak to be over $6000 per 30-day period, with an estimated incidence of death of 0.75/100 residents during the same period.¹⁰ In this study, we explored the risk of acute respiratory and gastrointestinal infection associated with a visit to the emergency department among elderly residents of long-term care facilities.     

Risk of mycobacterial disease among cancer patients: A population-based cohort study in a TB endemic area

ObjectivesTuberculosis (TB) and nontuberculous mycobacteria (NTM) disease have similar symptoms, which makes them difficult to distinguish clinically and leads to the danger of NTM disease being neglected. The aim of this study was to assess the risk of developing mycobacterial disease among cancer patients.MethodsWe conducted a retrospective cohort study using a population-based database. The multivariable Cox proportional hazards model was adjusted to identify independent factors contributing to the development of mycobacterial disease in the cancer cohort.ResultsThe results showed that the increased risk of developing TB and NTM disease was 1.84-fold and 4.43-fold, respectively, in cancer patients compared with the general population. Advanced age (≥65years) and being male were risk factors for developing TB disease. There was a 4.09-fold significantly increased risk of TB disease within six months of a cancer diagnosis. Hematological cancer patients were most likely to develop mycobacterial disease. Younger hematological cancer patients (< 45years) had a higher risk of NTM disease development.ConclusionThere is an increasing risk of mycobacterial disease in cancer patients. We suggest that the possibility of mycobacterial disease in cancer patients should be assessed during the period of cancer therapy, particularly in those who have risk factors.     

Risk of interpersonal violence during and after pregnancy among people with schizophrenia: a population-based cohort study

Background:Schizophrenia is associated with increased risk of experiencing interpersonal violence. Little is known about risk specifically around the time of pregnancy.Methods:This population-based cohort study included all individuals (aged 15–49 yr) listed as female on their health cards who had a singleton birth in Ontario, Canada, between 2004 and 2018. We compared those with and without schizophrenia on their risk of an emergency department (ED) visit for interpersonal violence in pregnancy or within 1 year postpartum. We adjusted relative risks (RRs) for demographics, prepregnancy history of substance use disorder and history of interpersonal violence. In a subcohort analysis, we used linked clinical registry data to evaluate interpersonal violence screening and self-reported interpersonal violence during pregnancy.Results:We included 1 802 645 pregnant people, 4470 of whom had a diagnosis of schizophrenia. Overall, 137 (3.1%) of those with schizophrenia had a perinatal ED visit for interpersonal violence, compared with 7598 (0.4%) of those without schizophrenia, for an RR of 6.88 (95% confidence interval [CI] 5.66–8.37) and an adjusted RR of 3.44 (95% CI 2.86–4.15). Results were similar when calculated separately for the pregnancy (adjusted RR 3.47, 95% CI 2.68–4.51) period and the first year postpartum (adjusted RR 3.45, 95% CI 2.75–4.33). Pregnant people with schizophrenia were equally likely to be screened for interpersonal violence (74.3% v. 73.8%; adjusted RR 0.99, 95% CI 0.95–1.04), but more likely to self-report it (10.2% v. 2.4%; adjusted RR 3.38, 95% CI 2.61–4.38), compared with those without schizophrenia. Among patients who did not self-report interpersonal violence, schizophrenia was associated with an increased risk for a perinatal ED visit for interpersonal violence (4.0% v. 0.4%; adjusted RR 6.28, 95% CI 3.94–10.00).Interpretation:Pregnancy and postpartum are periods of higher risk for interpersonal violence among people with schizophrenia compared with those without schizophrenia. Pregnancy is a key period for implementing violence prevention strategies in this population.

Interpersonal violence is defined as the intentional use of force or power against others, including physical, sexual and psychological abuse perpetrated by strangers, acquaintances, family members or intimate partners.^1–5 Around the time of pregnancy, interpersonal violence affects not only the person experiencing it, but also the developing fetus or infant.⁶ Maternal consequences include acute injuries, chronic pain and psychiatric disorders.^7,8 Interpersonal violence is also associated with absent or delayed prenatal care, preterm birth, poor fetal growth, difficulties in maternal–child attachment, and maternal, fetal and neonatal death.^9–14Women with schizophrenia are at high risk of experiencing interpersonal violence during their lifetime from known and unknown perpetrators.^15–17 The lifetime prevalence of physical or sexual assault in this population is 20.7%, about 9 times the risk of those without serious mental illness.¹⁸ Many women with schizophrenia become pregnant, but little is known about their risk of experiencing interpersonal violence around this time.^19,20 In 2 small clinical studies, rates of self-reported interpersonal violence in pregnancy were upward of 20%.^21,22 However, these studies had no comparator groups without schizophrenia, included only self-reported risk and did not evaluate postpartum risk.We sought to compare the risk of an emergency department (ED) visit for interpersonal violence during pregnancy and until 1 year postpartum among people with and without schizophrenia in Ontario. We also sought to compare rates of interpersonal violence screening and disclosure in response to screening in these 2 groups, as well as risk for an ED visit for interpersonal violence in pregnancy or within the first year postpartum among those who did not self-report interpersonal violence. The latter question is important given that people with schizophrenia report being concerned that disclosure of any social issues during the perinatal period could possibly lead to undesirable consequences, such as child apprehension.^23,24     

First Nations status and emergency department triage scores in Alberta: a retrospective cohort study

Background:Previous studies have found that race is associated with emergency department triage scores, raising concerns about potential health care inequity. As part of a project on quality of care for First Nations people in Alberta, we sought to understand the relation between First Nations status and triage scores.Methods:We conducted a population-based retrospective cohort study of health administrative data from April 2012 to March 2017 to evaluate acuity of triage scores, categorized as a binary outcome of higher or lower acuity score. We developed multivariable multilevel logistic mixed-effects regression models using the levels of emergency department visit, patient (for patients with multiple visits) and facility. We further evaluated the triage of visits related to 5 disease categories and 5 specific diagnoses to better compare triage outcomes of First Nations and non–First Nations patients.Results:First Nations status was associated with lower odds of receiving higher acuity triage scores (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.92–0.94) compared with non–First Nations patients in adjusted models. First Nations patients had lower odds of acute triage for all 5 disease categories and for 3 of 5 diagnoses, including long bone fractures (OR 0.82, 95% CI 0.76–0.88), acute upper respiratory infection (OR 0.90, 95% CI 0.84–0.98) and anxiety disorder (OR 0.67, 95% CI 0.60–0.74).Interpretation:First Nations status was associated with lower odds of higher acuity triage scores across a number of conditions and diagnoses. This may reflect systemic racism, stereotyping and potentially other factors that affected triage assessments.

Health outcomes are markedly worse for First Nations than non–First Nations people. Although this is largely because of inequities in the social determinants of health,^1–4 inequities in the provision of health care also exist.^5,6 Emergency departments serve as a point of accessible health care. Status First Nations patients make up 4.8% of unique patients and 9.4% of emergency visits in Alberta,⁷ and Canadian studies describe First Nations patients’ experiences with racism when seeking emergency care.^8,9Evaluating triage contributes empirically to understanding the health care of First Nations patients insofar as triage is a quantifiable, intermediate process by which systemic racism¹⁰ may influence patient outcomes. The Canadian Triage Acuity Scale¹¹ is a 5-level scale used to classify the severity of patient symptoms. Triage nurses use a brief assessment, medical history, and presenting signs and symptoms to assign each patient a triage score that determines the priority in which the patient should be seen by a provider. Therefore, accurate triage is important for patient health outcomes.¹² In practice, triage is a social interaction where local practice, biases, stereotypes and communication barriers come into play. Studies have found that women receive less acute triage scores than men,^13,14 and that racial minority^13,15–17 and Indigenous^18–20 patients receive less acute triage scores than white or non-Indigenous patients. Indeed, Indigenous patients in Canada have described a perception “of social triaging in the [emergency department], whereby decisions about who is seen first seemed to them [to be] based less on triaged clinical priorities but on the social positioning of the patient.”²¹ Differential triage scores for minority populations raise health equity concerns.As part of a larger mixed-methods project evaluating the quality of emergency care for First Nations people in Alberta, we sought to evaluate quantitative differences in emergency visit characteristics and outcomes of First Nations and non–First Nations people in Alberta. Specifically, we aimed to estimate the relation between First Nations status and acuity of triage, and to evaluate whether predictors of acuity differ by First Nations status.     

Disability in young people and adults one year after head injury: prospective cohort study

ObjectiveTo determine the frequency of disability in young people and adults admitted to hospital with a head injury and to estimate the annual incidence in the community.DesignProspective, hospital based cohort study, with one year follow up of sample stratified by coma score.SettingFive acute hospitals in Glasgow.Subjects2962 patients (aged 14 years or more) with head injury; 549 (71%) of the 769 patients selected for follow up participated.ResultsSurvival with moderate or severe disability was common after mild head injury (47%, 95% confidence interval 42% to 52%) and similar to that after moderate (45%, 35% to 56%) or severe injury (48%, 36% to 60%). By extrapolation from the population identified (90% of whom had mild injuries), it was estimated that annually in Glasgow (population 909 498) 1400 young people and adults are still disabled one year after head injury.ConclusionThe incidence of disability in young people and adults admitted with a head injury is higher than expected. This reflects the high rate of sequelae previously unrecognised in the large number of patients admitted to hospital with an apparently mild head injury.     

Cancer risk among young men with weight gain after smoking cessation: A population-based cohort study

BackgroundSmoking cessation may help the current smokers to reduce cancer risk. However, weight gain following smoking cessation may attenuate the protective association of cessation with cancer.Patients and methodsOur study included 1,278,794 men who were aged 20–39 years and underwent two consecutive health examinations by the National Health Insurance Service, without previous diagnosis of cancer. Participants were categorized into continual smokers, quitters with different degree of body weight change, and never smokers based on the biennial national health screening program (2002–2003 and 2004–2005) and were followed from January 1, 2006 to December 31, 2015. Cox proportional hazard models and restricted cubic spline model was used to evaluate the association of post-cessation weight change and cancer risk after adjustment for potential confounders.ResultsDuring the 10 years of follow-up, the analyses included 1,278,794 men with 21,494 cancer incidences. Compared to continual smokers, quitters without weight gain of 2.0 kg had significantly lower risk of obesity-related cancer (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.79-0.97), smoking-related cancer (HR, 0.90; 95% CI, 0.83 to 0.98), and gastrointestinal cancer (HR, 89; 95% CI, 0.80 to 0.98). Weight gain among quitters attenuated the risk reduction of cancer compared to continual smoking. Among quitters, weight gain up to 5.0 kg with smoking cessation showed protective association with cancer risk among quitters without weight gain.ConclusionExcessive weight gain with smoking cessation among quitters was not associated with reduced risk of several cancer types. This association should be taken into account when recommending smoking cessation to prevent cancer     

Stress and survival after cancer: a prospective study of a Finnish population-based cohort

Stress has been suggested to reduce survival after cancer, but the results of previous studies have been contradictory. We investigated the hypothesis in a national cohort of adults in Finland. Of those who completed the Stressful Life Events scale and the Stress of Daily Activities scale, 1470 and 1882, respectively, later had cancer and were included in the analysis, covering 23 years of follow-up between 1982 and 2004. In Cox regression analysis, the multivariate hazard ratio (HR) was 0.99 (95% confidence interval [CI], 0.96-1.01) for total number of life events and the HR for the life change score was 0.99 (95% CI, 0.95-1.03). Further, the HR was 0.92 (95% CI, 0.69-1.22) for severe daily stress. Overall, the results of the current study do not support the hypothesis that stress reduces cancer survival.     

Incidence of neurologic death among patients with brain injury: a cohort study in a Canadian health region

Background:

Hospital mortality has decreased over time for critically ill patients with various forms of brain injury. We hypothesized that the proportion of patients who progress to neurologic death may have also decreased.

Methods:

We performed a prospective cohort study involving consecutive adult patients with traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage or anoxic brain injury admitted to regional intensive care units in southern Alberta over a 10.5-year period. We used multivariable logistic regression to adjust for patient age and score on the Glasgow Coma Scale at admission, and to assess whether the proportion of patients who progress to neurologic death has changed over time.

Results:

The cohort consisted of 2788 patients. The proportion of patients who progressed to neurologic death was 8.1% at the start of the study period, and the adjusted odds of progressing to neurologic death decreased over the study period (odds ratio [OR] per yr 0.92, 95% confidence interval [CI] 0.87–0.98, p = 0.006). This change was most pronounced among patients with traumatic brain injury (OR per yr 0.87, 95% CI 0.78–0.96, p = 0.005); there was no change among patients with anoxic injury (OR per yr 0.96, 95% CI 0.85–1.09, p = 0.6). A review of the medical records suggests that missed cases of neurologic death were rare (≤ 0.5% of deaths).

Interpretation:

The proportion of patients with brain injury who progress to neurologic death has decreased over time, especially among those with head trauma. This finding may reflect positive developments in the prevention and care of brain injury. However, organ donation after neurologic death represents the major source of organs for transplantation. Thus, these findings may help explain the relatively stagnant rates of deceased organ donation in some regions of Canada, which in turn has important implications for the care of patients with end-stage organ failure.Mortality has decreased among critically ill patients with various forms of brain injury in Canada and around the world.^1–10 There have also been changes in the incidence of stroke and the rate of admission to hospital for traumatic brain injury, especially among younger people and those whose injuries are related to motor vehicle or bicycle crashes.^5,6,10–13Some countries have noted a possible decline in the total number of patients with neurologic death.^14,15 Neurologic death (“brain death”) may occur when patients with brain injury experience progressive cerebral edema, complicated by transtentorial herniation. It is defined by the irreversible cessation of cerebral and brainstem functions, including respiration.¹⁶ Circulation and gas exchange persist only because of the use of mechanical ventilation. National guidelines exist for the diagnosis of neurologic death.^17,18 We hypothesized that the proportion of patients with acute brain injury who progress to neurologic death may have decreased over time.     

The risk for depression in patients with ankylosing spondylitis: a population-based cohort study

Introduction

Depression is frequent in ankylosing spondylitis (AS) patients. However, epidemiological data about the potential increase in risk are lacking. This study compares the rate of doctor-diagnosed depression in a well defined cohort of AS patients to the general population seeking care.

Methods

The Skåne Healthcare Register comprises healthcare data of each resident in Region Skåne, Sweden (population 1.2 million), including ICD-10 diagnoses. Using physician coded consultation data from years 1999 to 2011, we calculated depression consultation rates for all AS patients. We obtained standardized depression-rate ratios by dividing the observed depression rate in AS patients by the expected rate based on the corresponding age- and sex-specific rates of depression in the general population seeking care. A ratio >1 equals a higher rate of depression among AS patients.

Results

The AS cohort consisted of 1738 subjects (65% men) with a mean age of 54 years. The reference population consisted of 967,012 subjects. During the 13-year observation period 10% (n = 172) of the AS cohort had a doctor-diagnosed depression compared to 6% (n = 105) to be expected. The standardized estimate of depression-rate ratio was 1.81 (95% confidence interval 1.44 to 2.24) in women men and 1.49 (1.20 to 1.89) in men.

Conclusions

The rate of doctor-diagnosed depression is increased about 80% in female and 50% in male AS patients. Future challenges are to timely identify and treat the AS patients who suffer from depression.     

Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older US Medicare beneficiaries with chronic noncancer pain: A population-based cohort study

BackgroundGabapentinoids are increasingly prescribed to manage chronic noncancer pain (CNCP) in older adults. When used concurrently with opioids, gabapentinoids may potentiate central nervous system (CNS) depression and increase the risks for fall. We aimed to investigate whether concurrent use of gabapentinoids with opioids compared with use of opioids alone is associated with an increased risk of fall-related injury among older adults with CNCP.Methods and findingsWe conducted a population-based cohort study using a 5% national sample of Medicare beneficiaries in the United States between 2011 and 2018. Study sample consisted of fee-for-service (FFS) beneficiaries aged ≥65 years with CNCP diagnosis who initiated opioids. We identified concurrent users with gabapentinoids and opioids days’ supply overlapping for ≥1 day and designated first day of concurrency as the index date. We created 2 cohorts based on whether concurrent users initiated gabapentinoids on the day of opioid initiation (Cohort 1) or after opioid initiation (Cohort 2). Each concurrent user was matched to up to 4 opioid-only users on opioid initiation date and index date using risk set sampling. We followed patients from index date to first fall-related injury event ascertained using a validated claims-based algorithm, treatment discontinuation or switching, death, Medicare disenrollment, hospitalization or nursing home admission, or end of study, whichever occurred first. In each cohort, we used propensity score (PS) weighted Cox models to estimate the adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) of fall-related injury, adjusting for year of the index date, sociodemographics, types of chronic pain, comorbidities, frailty, polypharmacy, healthcare utilization, use of nonopioid medications, and opioid use on and before the index date. We identified 6,733 concurrent users and 27,092 matched opioid-only users in Cohort 1 and 5,709 concurrent users and 22,388 matched opioid-only users in Cohort 2. The incidence rate of fall-related injury was 24.5 per 100 person-years during follow-up (median, 9 days; interquartile range [IQR], 5 to 18 days) in Cohort 1 and was 18.0 per 100 person-years during follow-up (median, 9 days; IQR, 4 to 22 days) in Cohort 2. Concurrent users had similar risk of fall-related injury as opioid-only users in Cohort 1(aHR = 0.97, 95% CI 0.71 to 1.34, p = 0.874), but had higher risk for fall-related injury than opioid-only users in Cohort 2 (aHR = 1.69, 95% CI 1.17 to 2.44, p = 0.005). Limitations of this study included confounding due to unmeasured factors, unavailable information on gabapentinoids’ indication, potential misclassification, and limited generalizability beyond older adults insured by Medicare FFS program.ConclusionsIn this sample of older Medicare beneficiaries with CNCP, initiating gabapentinoids and opioids simultaneously compared with initiating opioids only was not significantly associated with risk for fall-related injury. However, addition of gabapentinoids to an existing opioid regimen was associated with increased risks for fall. Mechanisms for the observed excess risk, whether pharmacological or because of channeling of combination therapy to high-risk patients, require further investigation. Clinicians should consider the risk–benefit of combination therapy when prescribing gabapentinoids concurrently with opioids.

In a cohort study, Cheng Chen and colleagues investigate associations between concurrent use of gabapentinoids and opioids and risk of fall-related injury, compared with use of opioids alone, among adults aged 65 years or older with chronic noncancer pain in the United States.     

The risk of stroke after percutaneous vertebroplasty for osteoporosis: a population-based cohort study

Purpose

To investigate the incidence and risk of stroke after percutaneous vertebroplasty in patients with osteoporosis.

Methods

A group of 334 patients with osteoporosis, and who underwent percutaneous vertebroplasty during the study period, was compared to 1,655 age-, sex- and propensity score-matched patients who did not undergo vertebroplasty. All demographic covariates and co-morbidities were deliberately matched between the two groups to avoid selection bias. Every subject was followed-up for up to five years for stroke. Adjustments using a Cox regression model and Kaplan-Meier analyses were conducted.

Results

A total of 1,989 osteoporotic patients were followed up for 3,760.13 person-years. Overall, the incidence rates of any stroke, hemorrhagic stroke and ischemic stroke were 22.6, 4.2 and 19.6 per 1,000 person-years, respectively. Patients who underwent vertebroplasty were not more likely to have any stroke (crude hazard ratio = 1.13, p = 0.693), hemorrhagic stroke (HR = 2.21, p = 0.170), or ischemic stroke (HR = 0.96, p = 0.90). After adjusting for demographics, co-morbidities and medications, the vertebroplasty group had no significant difference with the comparison group in terms of any, hemorrhagic and ischemic strokes (adjusted HR = 1.22, 3.17, and 0.96, p = 0.518, 0.055, and 0.91, respectively).

Conclusions

Osteoporotic patients who undergo percutaneous vertebroplasty are not at higher risk of any stroke in the next five years after the procedure.     

High-sensitivity cardiac troponin T for diagnosis of NSTEMI in the elderly emergency department patient: a clinical cohort study

Purpose: The aim of this study is to evaluate the impact of age on the diagnostic performance of high-sensitivity troponin T (hsTnT) under routine conditions.

Materials and methods: Data of 4118 consecutive emergency department (ED) patients who underwent a routine TnT measurement between 11 October 2012 and 30 November 2013 were analysed. Diagnostic accuracy of hsTnT was compared in four age categories (<50, 50–64, 65–74, ≥75 years of age) for different cut-off values. Primary endpoint was a main hospital diagnosis of NSTEMI.

Results: The median age of the study population (n?=?4118) was 61 years (IQR: 45–75 years). NSTEMI was diagnosed in 3.3% (n?=?136) of all patients. There were significant differences in hsTnT concentrations between age-groups (p?p?=?0.297). 72.2% of all patients ≥75 years of age (583/808) without NSTEMI had hsTnT concentrations above the 99th percentile of a healthy reference population. Specificity at 14?ng/L was 93.6% (95% CI: 92.12–94.87) in patients below 50 years of age and 27.9% (95% CI: 24.78–31.08) in patients 75 years of age and older.

Conclusions: Patients’ age needs to be considered at least one influencing factor on hsTnT concentrations at admission and should be included in the clinical interpretation of hsTnT concentrations for further clinical workup beneath other influencing factors like comorbidities and symptom onset time. The implementation of age-specific cut-off values could be considered for single troponin testing at admission but is associated with an increased risk of underdiagnosis of NSTEMI.     

Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study

Background:Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults.Methods:We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits.Results:We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14).Interpretation:Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.

In the continuum of care services and settings for older adults lies home care at one end and long-term care at the other.¹ Home care services may include, but are not limited to, nursing care, personal care, homemaking services, and physiotherapy and occupational therapy for older adults who live independently in their community. Home care services are publicly funded under the Ontario Health Insurance Plan (OHIP).^2,3 Long-term care homes provide access to 24-hour nursing and personal care and operate at full capacity in Ontario, with waiting lists of 6 months or longer before an older adult in the community could receive an offer for a bed.^2,4 Retirement homes are thought to fit between home care and long-term care in this continuum.¹Retirement homes are referred to as assisted-living facilities in other North American jurisdictions, and they are private, congregate living environments that deliver supportive care to adults who are 65 years of age and older.^3,5,6 These homes are often marketed to provide a lifestyle and community, and they provide a range of assisted-living care services (e.g., meals, nursing services, etc.).^5,7 Retirement homes predominately operate on a private, for-profit business model, and the room, board and services are purchased by residents.^3,5 In Ontario, retirement homes are regulated through an independent, not-for-profit regulator (i.e., Retirement Homes Regulatory Authority [RHRA]).⁵ There are more than 700 licensed retirement homes in Ontario with over 70 000 available beds occupied by over 55 000 residents, which is comparable to the number of available beds in the long-term care sector.^3,5,6,8 Retirement homes are legislated differently from long-term care homes and primarily cater to adults who do not require 24-hour nursing care.^1,5,9 Unlike long-term care homes, no standardized reporting system is available to identify and describe residents of retirement homes.¹⁰ These residents are conceptualized as having fewer needs for care because they reside in a congregate care home to support independent living; however, this has been difficult to verify given there are no population-level data.A body of literature from the United States has described residents of assisted-living facilities and the sector,^11–17 but Canadian literature is comparatively nascent. Canadian studies have investigated transitions to a long-term care home, risk of hospital admission among those who live with dementia, and life events and health conditions associated with the transition to a congregate care setting.^7,9,18–20 At present, a Canadian population-level cohort of residents of retirement homes that describes the individual-level characteristics and use of health services of the older adults who reside in these homes appears to be lacking. Therefore, it is difficult to position this sector in the gradient of services and housing options for older adults in Canada.We created a population-level cohort of residents in retirement homes and sought to evaluate their rates of health services utilization relative to residents of long-term care homes and other populations of older adults (i.e., home care recipients and community-dwelling older adults) in Ontario.     

Reducing all-cause mortality among patients with psychiatric disorders: a population-based study

Background:

Among patients with psychiatric disorders, there are 10 times as many preventable deaths from physical disorders as there are from suicide. We investigated whether compulsory community treatment, such as community treatment orders, could reduce all-cause mortality among patients with psychiatric disorders.

Methods:

We conducted a population-based survival analysis of an inception cohort using record linking. The study period extended from November 1997 to December 2008. The cohort included patients from all community-based and inpatient psychiatric services in Western Australia (state population 1.8 million). We used a 2-stage design of matching and Cox regression to adjust for demographic characteristics, previous use of health services, diagnosis and length of psychiatric history. We collected data on successive cohorts for each year for which community treatment orders were used to measure changes in numbers of patients, their characteristics and outcomes. Our primary outcome was 2-year all-cause mortality. Our secondary outcomes were 1-and 3-year all-cause mortality.

Results:

The study population included 2958 patients with community treatment orders (cases) and 2958 matched controls (i.e., patients with psychiatric disorders who had not received a community treatment order). The average age for cases and controls was 36.7 years, and 63.7% (3771) of participants were men. Schizophrenia and other nonaffective psychoses were the most common diagnoses (73.4%) among participants. A total of 492 patients (8.3%) died during the study. Cox regression showed that, compared with controls, patients with community treatment orders had significantly lower all-cause mortality at 1, 2 and 3 years, with an adjusted hazard ratio of 0.62 (95% confidence interval 0.45–0.86) at 2 years. The greatest effect was on death from physical illnesses such as cancer, cardiovascular disease or diseases of the central nervous system. This association disappeared when we adjusted for increased outpatient and community contacts with psychiatric services.

Interpretation:

Community treatment orders might reduce mortality among patients with psychiatric disorders. This may be partly explained by increased contact with health services in the community. However, the effects of uncontrolled confounders cannot be excluded.Mortality among patients with psychiatric disorders is higher than in the general population.¹ Chronic physical disorders such as cardiovascular disease and cancer are the main causes of death in this population, with risks 10 times that of suicide; however, such causes receive far less attention than suicides.^1,2 Patients with schizophrenia die 15–20 years earlier than people in the general population, a difference that has increased over time.^1,3 Reasons for this difference include socioeconomic disadvantage, adverse effects of medication and reduced access to health care.^4,5There are limited data on possible interventions aimed at preventing such deaths, most of which stress regular monitoring of physical status, peer support and collaboration with primary care.^6,7 One study from Victoria, Australia, found that patients on conditional release from hospital had lower mortality than expected when use of community care, age, sex, inpatient experience and diagnosis were taken into account.⁸ However, 10% of these patients had dementia or other diseases of the nervous system, and patients with these diagnoses made up 29% of the deaths in the study. Dementia is not a typical indication for compulsory community treatment. In addition, Victoria has one of the highest levels of use of community treatment orders, about 60 per 100 000 population; thus, those results may not be generalizable to other locales.⁸ Although the authors controlled for time at risk, death could occur from 1 day to 11 years after the index date;⁹ most evaluations of community treatment orders are limited to 1 or 2 years after the order is issued.^9,10 Finally, the results were not adjusted for patients’ marital status, education, country of birth, indigenous status or use of health services before the introduction of community treatment orders. Adjusting for these variables could reduce the bias inherent in drawing cases and controls from the same jurisdiction given the difficulties in controlling for all possible reasons for issuing these orders once they have been introduced.We sought to assess the impact of community treatment orders on 1-, 2-, and 3-year survival in Western Australia. Community treatment orders provide a legal framework within which patients with a serious mental disorder are required to accept psychiatric treatment while living outside hospital. These orders are used across both Canada and Australia, are of similar duration in both countries, and are clinician-initiated rather than court-ordered (in contrast to the United States).^10,11 Unlike in Canada, patients in Australia can be given community treatment orders without having been previously admitted to hospital. In practice, patients in both countries spend similar amounts of time in hospital before being given a community treatment order.¹²We focused on deaths from physical illness, rather than suicides, as these are the most common causes of preventable death among people with severe mental illness.^1,2 We thought that patients with community treatment orders would have lower mortality because of improved engagement with health services, thus allowing greater monitoring and management of physical health. Greater engagement would be shown via increased outpatient contacts following the receipt of a community treatment order, which would influence any association between compulsory community treatment and mortality.