Will hospital closures mean physician unemployment in Ontario?

Dr. Duncan Sinclair, the former dean of medicine who heads the commission charged with restructuring Ontario''s health care system, said something dramatic was needed to revamp the system. He wasn''t kidding. His commission recently called for the closure of 3 hospitals in Ottawa and 10 more in Toronto. In a wideranging interview with Charlotte Gray he talks about the commission''s goals and their potential impact on physicians.     

Prevalence and clinical characteristics of diabetic peripheral neuropathy in hospital patients with Type 2 diabetes in Korea

Diabet. Med. 29, e290-e296 (2012) ABSTRACT: Aims Diabetic peripheral neuropathy is a common complication of diabetes. This cross-sectional study investigated the prevalence and clinical characteristics of this neuropathy in patients with Type?2 diabetic mellitus treated at hospitals in Korea. Methods Questionnaires and medical records were used to collect data on 4000 patients with Type?2 diabetes from the diabetes clinics of 40 hospitals throughout Korea. Diabetic peripheral neuropathy was diagnosed based on a review of medical records or using the Michigan Neuropathy Screening Instrument score and monofilament test. Results The prevalence of neuropathy was 33.5% (n?=?1338). Multivariate analysis revealed that age, female sex, diabetes duration, lower glycated haemoglobin, treatment with oral hypoglycaemic agents or insulin, presence of retinopathy, history of cerebrovascular or peripheral arterial disease, presence of hypertension or dyslipidaemia, and history of foot ulcer were independently associated with diabetic peripheral neuropathy. Of the patients with neuropathy, 69.8% were treated for the condition and only 12.6% were aware of their neuropathy. Conclusion There was a high prevalence of peripheral neuropathy in patients with Type?2 diabetes in Korea and those patients were far more likely to have complications or co-morbidities. The proper management of diabetic peripheral neuropathy deserves attention from clinicians to ensure better management of diabetes in Korea.     

Hereditary hemochromatosis in a Brazilian university hospital in São Paulo State (1990-2000)

Hereditary hemochromatosis (HH) is the most common genetic disease among individuals of European descent. Two mutations (845G-->A, C282Y and 187C-->G, H63D) in the hemochromatosis gene (HFE gene) are associated with HH. About 85-90% of patients of northern European descent with HH are C282Y homozygous. The prevalence of HH in the Brazilian population, which has a very high level of racial admixture, is unknown. The aims of the present study were to identify individuals with diagnostic criteria for HH among patients with a body iron overload attended at the university hospital of the Faculty of Medicine of Ribeirao Preto from 1990 to 2000, and to evaluate the prevalence of HFE mutations. We screened first-degree relatives for HFE mutations. Four of 72 patients (three men and one woman, mean age 47 years) fulfilled the criteria for HH. HFE mutations were studied in three patients [two C282Y homozygotes (patients 1 and 2) and one H63D heterozygote]. Patient 1 had four children (all C282Y heterozygotes with no iron overload) and seven brothers and sisters: two sisters (66 and 76 years old) were C282Y homozygotes and both had an iron overload (a liver biopsy in one showed severe iron deposits), one sister (79 years old) was a compound heterozygote with no iron overload, one brother (78 years old) was a C282Y heterozygote with no iron overload, two individuals were H63D heterozygotes (one brother, 49 years old, obese, with a body iron overload and abnormal liver enzymes - a biopsy showed non-alcoholic steatohepatitis, and one 70-year-old sister with no iron overload). Patient 2 had two children (22 and 24 years old who were C282Y heterozygotes with no iron overload) but no brothers or sisters. These results showed that HH was uncommon among individuals attended at our hospital, although HFE mutations were found in all patients. Familial screening is valuable for the early diagnosis of individuals at risk since it allows treatment to be initiated before the onset of the clinical manifestations of organ damage associated with HH.     

Under-use of adjuvant chemotherapy in women aged ≥70 years diagnosed with breast cancer in a university hospital

Introduction

Patient age often limits the therapeutic efforts of the oncologist. The aim of this study was to determine whether chemotherapy is used less frequently in elderly women aged 65-69 years diagnosed with breast cancer, compared to younger women.

Methods

A retrospective study was performed including women greater than 65 years old who had localised breast cancer and were treated at a University Hospital. Patients were classified into two groups, 65-69 years old and ≥ 70 years old. The differences in patient characteristics, tumour characteristics, chemotherapy treatment and chemotherapy-associated toxicity were analysed in both groups.

Results

A total of 164 women, with an average age of 73.7 years, were included in this study. There were no significant differences in the characteristics of the patients or their tumours. However, 75% of women <70 years old were treated with chemotherapy compared to just 34% of the older women (P<.001). The resulting levels of toxicity were similar between age groups.

Conclusions

Women ≥ 70 years old were treated with chemotherapy less frequently, even though the features and tumour characteristics of the women, as well as the toxicity of the treatment, were similar to that in younger women.     

What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families

Background:

The guideline-recommended elements to include in discussions about goals of care with patients with serious illness are mostly based on expert opinion. We sought to identify which elements are most important to patients and their families.

Methods:

We used a cross-sectional study design involving patients from 9 Canadian hospitals. We asked older adult patients with serious illness and their family members about the occurrence and importance of 11 guideline-recommended elements of goals-of-care discussions. In addition, we assessed concordance between prescribed goals of care and patient preferences, and we measured patient satisfaction with goals-of-care discussions using the Canadian Health Care Evaluation Project (CANHELP) questionnaire.

Results:

Our study participants included 233 patients (mean age 81.2 yr) and 205 family members (mean age 60.2 yr). Participants reported that clinical teams had addressed individual elements of goals-of-care discussions infrequently (range 1.4%–31.7%). Patients and family members identified the same 5 elements as being the most important to address: preferences for care in the event of life-threatening illness, values, prognosis, fears or concerns, and questions about goals of care. Addressing more elements was associated with both greater concordance between patients’ preferences and prescribed goals of care, and greater patient satisfaction.

Interpretation:

We identified elements of goals-of-care discussions that are most important to older adult patients in hospital with serious illness and their family members. We found that guideline-recommended elements of goals-of-care discussions are not often addressed by health care providers. Our results can inform interventions to improve the determination of goals of care in the hospital setting.In Canada, dying is often an in-hospital, technology-laden experience.^1–4 Rates of cardiopulmonary resuscitation (CPR) before death continue to increase among older adult patients in hospital,⁵ and one-fifth of deaths in hospital occur in an intensive care unit.^1,2,6,7 These observations contrast sharply with patient-reported preferences. A recent Canadian study found that 80% of older adult patients in hospital with a serious illness prefer a less aggressive and more comfort-oriented end-of-life care plan that does not include CPR.⁸Such patients and their families have identified communication with health care providers and decision-making about goals of care as high priorites for improving end-of-life care in Canada.^9,10 We define “decision-making about goals of care” as an end-of-life communication and decision-making process that occurs between a clinician and a patient (or a substitute decision-maker if the patient is incapable) in an institutional setting to establish a plan of care. Often, this process includes deciding whether to use life-sustaining treatments.¹¹ Current guidelines recommend that health care providers address 11 key elements when discussing goals of care with patients and families (Box 1).^12–14 However, these elements are mostly based on expert opinion and lack input from patients and their families.

Box 1:

Key elements of goals-of-care discussions with patients in hospital with serious illness^12–14

• Ask about previous discussions or written documentation about the use of life-sustaining treatments
• Offer a time to meet to discuss goals of care
• Provide information about advance care planning to review before conversations with the physician
• Disclose prognosis
• Ask about patients’ values (i.e., what is important to them when considering health care decisions)
• Provide information about outcomes, benefits and risks of life-sustaining treatments
• Provide information about outcomes, benefits and risks of comfort measures
• Prompt for additional questions about goals of care
• Provide an opportunity to express fears or concerns
• Ask about preferences for care in the event of a life-threatening illness
• Facilitate access to legal documents to record patients’ wishes

Our primary objective was to determine which of these elements are most important to patients and their families. In addition, we examined whether these discussions were associated with concordance between patients’ (or family members’) preferences and prescribed goals of care, and with satisfaction with end-of-life communication and decision-making.     

How long should patients with suspected myocardial infarction be under observation in hospital?

Out of 368 patients admitted to hospital for chest pain and suspected acute myocardial infarction, 267 were discharged within 24 hours on the basis of the clinical picture, electrocardiogram, and serum activities of aspartate transaminase, alpha-hydroxybutyrate dehydrogenase, and creatine phosphokinase. The patients were followed up for 28 days, during which 17 were readmitted, two of them twice and one three times. Two of the patients were readmitted with non-fatal acute myocardial infarction, and two died. The patients had been primarily divided into two groups: those admitted with presumably non-coronary chest pain (77 patients) formed group 1 and those with obvious coronary chest pain (190 patients) group 2. Both deaths occurred in patients in group 2 but the incidences of events during the follow-up period were otherwise similar in the two groups, and some patients in both groups may have had small acute myocardial infarctions when first admitted. The decision to keep in hospital or discharge a patient with chest pain of recent onset can be made within 24 hours of admission. To discharge the patient acute myocardial infarction need not necessarily be excluded and conventional tests are enough to enable a decision to be made.     

The molecular epidemiology of Stenotrophomonas maltophilia bacteraemia in a tertiary referral hospital in the United Arab Emirates 2000–2004

Background

Methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly prevalent worldwide since it was first reported in a British hospital. The prevalence however, varies markedly in hospitals in the same country, and from one country to another. We therefore sought to document comprehensively the prevalence and antimicrobial susceptibility pattern of MRSA isolates in Trinidad and Tobago.

Methods

All Staphylococcus aureus isolates encountered in routine clinical specimens received at major hospitals in the country between 2000 and 2001 were identified morphologically and biochemically by standard laboratory procedures including latex agglutination test (Staphaurex Plus; Murex Diagnostics Ltd; Dartford, England); tube coagulase test with rabbit plasma (Becton, Dickinson & Co; Sparks, MD, USA), and DNase test using DNase agar (Oxoid Ltd; Basingstoke, Hampshire, England). MRSA screening was performed using Mueller-Hinton agar containing 6 μg oxacillin and 4% NaCl, latex agglutination test (Denka Seiken Co. Ltd, Tokyo, Japan) and E-test system (AB Biodisk, Solna, Sweden). Susceptibility to antimicrobial agents was determined by the modified Kirby Bauer disc diffusion method while methicillin MICs were determined with E-test system.

Results

Of 1,912 S. aureus isolates received, 12.8% were methicillin (oxacillin) resistant. Majority of the isolates were recovered from wound swabs (86.9%) and the least in urine (0.4%) specimens. Highest number of isolates was encountered in the surgical (62.3%) and the least from obstetrics and gynaecology (1.6%) facilities respectively. Large proportions of methicillin sensitive isolates are >85% sensitive to commonly used and available antimicrobials in the country. All MRSA isolates were resistant to ceftriaxone, erythromycin, gentamicin and penicillin but were 100% sensitive to vancomycin, rifampin and chloramphenicol.

Conclusion

There is a progressive increase in MRSA prevalence in the country but the present rate is still low in comparison to values in some other countries. Vancomycin is still the drug of choice for treating multidrug resistant MRSA infections. Further use of molecular studies to monitor the epidemiology of MRSA in these hospitals in the country is highly recommended too.     

Trends in 1-year survival of people admitted to hospital in Ontario, 1994–2009

Background:

Changes in the long-term survival of people admitted to hospital is unknown. This study examined trends in 1-year survival of patients admitted to hospital adjusted for improved survival in the general population.

Methods:

One-year survival after admission to hospital was determined for all adults admitted to hospital in Ontario in 1994, 1999, 2004, or 2009 by linking to vital statistics datasets. Annual survival in the general population was determined from life tables for Ontario.

Results:

Between 1994 and 2009, hospital use decreased (from 8.8% to 6.3% of the general adult population per year), whereas crude 1-year mortality among people with hospital admissions increased (from 9.2% to 11.6%). During this time, patients in hospital became significantly older (median age increased from 51 to 58 yr) and sicker (the proportion with a Charlson comorbidity index score of 0 decreased from 68.2% to 60.0%), and were more acutely ill on admission (elective admissions decreased from 47.4% to 42.0%; proportion brought to hospital by ambulance increased from 16.1% to 24.8%). Compared with 1994, the adjusted odds ratio (OR) for death at 1 year in 2009 was 0.78 (95% confidence interval [CI] 0.77–0.79). However, 1-year risk of death in the general population decreased by 24% during the same time. After adjusting for improved survival in the general population, risk of death at 1 year for people admitted to hospital remained significantly lower in 2009 than in 1994 (adjusted relative excess risk 0.81, 95% CI 0.80–0.82).

Interpretation:

After accounting for both the increased burden of patient sickness and improved survival in the general population, 1-year survival for people admitted to hospital increased significantly from 1994 to 2009. The reasons for this improvement cannot be determined from these data. Hospitals have a special place in most health care systems. Hospital staff care for the people with the most serious illnesses and the most vulnerable. They are frequently the location of many life-defining moments — including birth, surgery, acute medical illness and death — of many people and their families. Hospitals serve as a focus in the training of most physicians. In addition, they consume a considerable proportion of health care expenditures worldwide. ¹ Given the prominence of hospitals in health care systems, measuring outcomes related to hospital care is important. In particular, the measurement of trends for outcomes of hospital care can help us to infer whether the care provided to hospital patients is improving. Previous such studies have focused on survival trends for specific diseases or patients who received treatment in specific departments. ^{2 – 12} None of these studies have adjusted for survival trends in the general population, the adjustment for which is important to determine whether changes in survival of patients in hospital merely reflect changes in the overall population. In this study, whether or not patient outcomes have changed over time was determined by examining trends in 1-year survival in all patients admitted to hospital, adjusting for improved survival in the general population.     

EAHFE – TROPICA2 study. Prognostic value of troponin in patients with acute heart failure treated in Spanish hospital emergency departments

Objective: Evaluate the use of different cardiac troponin (cTn) immunoassays and the prognostic value of increased cTn values in patients diagnosed with acute heart failure (AHF) in the emergency department (ED).

Method: The epidemiology acute heart failure emergency-TROPonin in acute heart failure2 (EAHFE-TROPICA2) is a retrospective study including patients with AHF admitted in 34 Spanish EDs with cTn values determined in the ED. We studied the prevalence of elevated troponin (value above the established reference limit) for the different types of troponin. We also assessed crude and adjusted primary (1-year all-cause death) and secondary (30 d ED revisit due to AHF) outcomes for every type of cTn and different magnitudes of troponin elevation.

Results: We analysed 4705 episodes of AHF. Troponin was elevated in 48.4% of the cases (25.3% in cTnI, 37.9% in cTnT and 82.2% in hs-cTnT). Mortality at one year was higher in patients with elevated troponin (adjusted HR 1.61; CI 95% 1.38–1.88) regardless of the type of cTn determined. Elevated troponin was not related to ED revisit within 30 d after discharge (1.01; 0.87–1.19).

Conclusions: The use of conventional troponin in the ED is useful to predict one-year mortality in patients with AHF. Highly sensitive cTnT (hs-cTnT) elevations less than double the reference value have no impact on patient outcome.     

Containing Ontario's hospital costs under universal insurance in the 1980s: what was the record?

In recent years the Ontario government has been concerned that the proportion of public expenditures devoted to health care is at an all-time high. In addition, the media have devoted considerable attention to specific incidents that may represent inadequate funding of hospital services. To shed light on the debate on health care expenditures we analysed the trend in expenditures of Ontario''s hospital sector in the 1980s in terms of the amount of inputs (e.g., labour) used to produce hospital services (e.g., a patient-day or admission) and after adjustment for general inflation. As in the 1970s the number of inputs grew relatively slowly during the 1980s. Inputs per patient-day grew at an annual rate of 0.46% and inputs per admission at an annual rate of 2.4%. Cost increases were largely accounted for by hospital wage increases; this could have been due to Ontario''s rapidly expanding economy. These findings indicate that Ontario has continued to be successful in containing the number of inputs used in the hospital sector. However, after two decades of substantial success with publicly acceptable cost control, the government faces increased scrutiny as the media and the public focus attention on several areas of perceived inadequate funding in health care services.