Heather D. Clark

Assessing the quality of randomized trials: reliability of the Jadad scale.

An instrument was developed and validated by Jadad, et al. to assess the quality of clinical trials using studies from the pain literature. Our study determined the reliability of the Jadad scale and the effect of blinding on interrater agreement in another group of primary studies. Four raters independently assessed blinded and unblinded versions of 76 randomized trials. Interrater agreement was calculated among combinations of four raters for blinded and unblinded versions of the studies. A 4 x 2 x 2 repeated measures design was employed to evaluate the effect of blinding. The interrater agreement for the Jadad scale was poor (kappa 0.37 to 0.39), but agreement improved substantially (kappa 0.53 to 0.59) with removal of the third item (an explanation of withdrawals). Blinding did not significantly affect the Jadad scale scores. A more precise description of how to score the withdrawal item and careful conduct of a practice set of articles might improve interrater agreement. In contrast with the conclusions reached by Jadad, we were unable to demonstrate a significant effect of blinding on the quality scores.

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital

Background: Adverse events are poor patient outcomes that are due to medical care. Studies of hospital patients have demonstrated that adverse events are common, but few data describe the timing of them in relation to hospital admission. We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing. Methods: We randomly selected 502 adults admitted to the Ottawa Hospital for acute care of nonpsychiatric illnesses over a 1-year period. Charts were reviewed in 2 stages. If an adverse event was judged to have occurred, a physician determined whether it occurred before or during the index hospitalization. The reviewer also rated the preventability, severity and type of each adverse event. Results: Of the 64 patients with an adverse event (incidence 12.7%, 95% confidence interval [CI] 10.1%–16.0%), 24 had a preventable event (4.8%, 95% CI 3.2%–7.0%), and 3 (0.6%, 95% CI 0.2%–1.7%) died because of an adverse event. Most adverse events were due to drug treatment, operative complications or nosocomial infections. Of the 64 patients, 39 (61%, 95% CI 49%–72%) experienced the adverse event before the index hospitalization. Interpretation: Adverse events were common in this study. However, only one-third were deemed avoidable, and most occurred before the hospitalization. Interventions to improve safety must address ambulatory care as well as hospital-based care.

Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial

OBJECTIVE Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates. STUDY DESIGN Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests. RESULTS OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P < .05). CONCLUSION Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.

Cystatin-C and beta trace protein as markers of renal function in pregnancy

Objective  To assess the validity of Cystatin‐C (Cys‐C) and beta trace protein (BTP) as clinical markers of glomerular filtration rate (GFR) in pregnant women.

What factors are associated with a woman's decision to take hormone replacement therapy? Evaluated in the context of a decision aid.

Objectives  To understand the factors associated with a post‐menopausal woman deciding to take hormone replacement therapy (HRT) after reviewing a decision aid (DA) and having a counselling visit with her physician as well as the factors associated with the act of taking HRT 2 months after the counselling interview.

Clinical predictors for diabetes screening in the first year postpartum after gestational diabetes

Background: Postpartum screening for diabetes in women with gestational diabetes (GDM) improves with use of reminder systems. Our primary objective was to identify predictors of diabetes screening in the first year after delivery. Methods: A retrospective study was performed of 556 women with GDM who received outpatient prenatal care between 2007 and 2009. A mailed reminder system was utilized at two sites. Rates of postpartum glucose testing at 6 and 12 months postpartum were measured. Results: Site of care and non-smoking status were identified as the only predictors of postpartum diabetes screening (p<0.001 and p = 0.02, respectively). Rates of OGTT completion at one year (38% vs. 19% p<0.001) were higher in women who attended clinics with postpartum reminders. Conclusions: The site of diabetes care in pregnancy is a major predictor of adherence to diabetes screening postpartum. Health care delivery should be considered in the development of strategies to increase screening rates.

The Evolution of General Internal Medicine (GIM)in Canada: International Implications

General internal medicine (GIM), like other generalist specialties, has struggled to maintain its identity in the face of mounting sub-specialization over the past few decades. In Canada, the path to licensure for general internists has been through the completion of an extra year of training after three core years of internal medicine. Until very recently, the Royal College of Physicians and Surgeons of Canada (RCPSC) did not recognize GIM as a distinct entity. In response to a societal need to train generalist practitioners who could care for complex patients in an increasingly complex health care setting, the majority of universities across Canada voluntarily developed structured GIM training programs independent of RCPSC recognition. However, interest amongst trainees in GIM was declining, and the GIM workforce in Canada, like that in many other countries, was in danger of serious shortfalls. After much deliberation and consultation, in 2010, the RCPSC recognized GIM as a distinct subspecialty of internal medicine. Since this time, despite the challenges in the educational implementation of GIM as a distinct discipline, there has been a resurgence of interest in this field of medicine. This paper outlines the journey of the Canadian GIM to educational implementation as a distinct discipline, the impact on the discipline, and the implications for the international GIM community.General internal medicine (GIM), like other generalist specialties, has struggled to maintain its identity in the face of mounting sub-specialization over the past few decades. In Canada, the path to licensure for general internists has been through the completion of an extra year of training after three core years of internal medicine. Until very recently, the Royal College of Physicians and Surgeons of Canada (RCPSC) did not recognize GIM as a distinct entity. In response to a societal need to train generalist practitioners who could care for complex patients in an increasingly complex health care setting, the majority of universities across Canada voluntarily developed structured GIM training programs independent of RCPSC recognition. However, interest amongst trainees in GIM was declining, and the GIM workforce in Canada, like that in many other countries, was in danger of serious shortfalls. After much deliberation and consultation, in 2010, the RCPSC recognized GIM as a distinct subspecialty of internal medicine. Since this time, despite the challenges in the educational implementation of GIM as a distinct discipline, there has been a resurgence of interest in this field of medicine. This paper outlines the journey of the Canadian GIM to educational implementation as a distinct discipline, the impact on the discipline, and the implications for the international GIM community.

A 2 hr oral glucose tolerance test will identify more women at risk for type 2 diabetes when screening postpartum in gestational diabetics.

A 2 hr oral glucose tolerance test will identify more women at risk for type 2 diabetes when screening postpartum in gestational diabetics. Heather D. Clark*, Alan Karovitch, Erin J Keely, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa, Ottawa ON The CDA 2003 Clinical Practice guidelines recommends screening women with gestational diabetes (GDM) in the first 6 months postpartum for type 2 Diabetes Mellitus (T2DM) with a 2 hour 75 g oral glucose tolerance test (2 hr GTT) as a fasting glucose may lead to under-diagnosis of T2DM (Grade D, consensus) and can not identify impaired glucose tolerance (IGT). We performed a randomized controlled trial evaluating the effect of postal reminders on screening rates in women with GDM. All women from this cohort who completed a 2 hr GTT were included. We determined the rates of impaired fasting glucose (IFG) and T2DM diagnosed by a fasting glucose and IGT and T2DM diagnosed by a 2 hr GTT. Of the 428 patients 156 women completed a 2 hr GTT. 20/156 (12.8%) were diagnosed with IFG, 27/156 (17.3%) were diagnosed with IGT and 4/156 (2.6%) were diagnosed with both. 3/156 (1.9%) women were diagnosed with T2DM by a fasting glucose and 8/156 (5.1%) were diagnosed based on the 2 hr glucose result only. If a two step testing strategy was utilized (i.e. only women with fasting glucose >5.6 mmol/L screened with 2 hr GTT ) 15/27 (56%) of women with IGT and 3/11 (27%) of women with T2DM would be missed. In summary, we found if women were screened postpartum with a fasting glucose alone or a two step screening strategy miss a substantial proportion of women with IGT and T2DM, were missed supporting the CDA recommendations.