Karen Okrainec

Impact of Language Barriers on Complications and Mortality Among Immigrants With Diabetes: A Population-Based Cohort Study

OBJECTIVE Our objective was to examine the effect of language barriers on the risk of acute and chronic complications of diabetes and on mortality among immigrants. RESEARCH DESIGN AND METHODS Linked health and immigration databases were used to identify 87,707 adults with diabetes who immigrated to Ontario, Canada, between 1985 and 2005. These individuals were included in our cohort and stratified by language ability at the time of their immigration application. Primary end points included: one or more emergency department visit or hospitalization for 1) hypo- or hyperglycemia, skin and soft tissue infection, or foot ulcer and 2) a cardiovascular event or death between April 1, 2005, and February 29, 2012. RESULTS Our cohort was followed up for a median of 6.9 person-years. Immigrants with language barriers were older (mean age, 49 ± 15 vs. 42 ± 13 years; P < 0.001), more likely to have immigrated for family reunification (66% vs. 38%, P < 0.001), had less education (secondary school or less and no education, 82% vs. 53%; P < 0.001), and a higher use of health care (mean visits, 8.6 ± 12.1 vs. 7.8 ± 11.2; P < 0.001). Immigrants with language barriers were not found to have higher adjusted rates of diabetes complications (acute complications: hazard ratio [HR] 0.99, 95% CI 0.93–1.05; cardiovascular events or death: HR 0.95, 95% CI 0.91–0.99). Significant predictors included older age, being unmarried, living in a rural neighborhood, and having less education. Immigrants who were older (≥65 years) and who had arrived through family reunification had a lower risk of cardiovascular events or death (HR 0.88, 95% CI 0.81–0.96). CONCLUSIONS In a heterogenous immigrant population with universal insurance, language barriers were not found to increase the risk of diabetes complications. However, their effect may vary based on age at time of landing, education level, marital status, and neighborhood of settlement.

Risk of cardiovascular events and mortality among a population-based cohort of immigrants and long-term residents with diabetes: Are all immigrants healthier and if so, for how long?

BACKGROUND Cardiovascular events are responsible for half of all deaths among individuals with diabetes. Immigrants to Western countries may experience an acceleration of cardiovascular risk in the first 10 years of arrival because of a sedentary lifestyle, poor diet, or barriers to accessing care, leading to higher levels of obesity and diabetes. OBJECTIVES To compare the risk of cardiovascular events and mortality between immigrants to Canada and long-term residents with diabetes and to assess whether immigrants experience acceleration in risk after arrival. METHODS We conducted a population-based retrospective cohort study using linked health and immigration data from Ontario, Canada, of 87,707 immigrants who immigrated to Canada between 1985 and 2005 matched to 87,707 long-term residents with diabetes (age ≥20 years). Individuals were followed up from April 1, 2005, until February 29, 2012, for the primary composite outcome of a cardiovascular event (acute myocardial infarction, unstable angina, congestive heart failure, transient ischemic attack, stroke) or all-cause mortality. RESULTS There was a lower adjusted risk of cardiovascular events or mortality among immigrants (adjusted hazard ratio [HR] 0.76, 95% CI 0.74-0.78) after accounting for differences in baseline age, gender, socioeconomic status, neighborhood, and health care utilization-which persisted beyond 10 years from immigration. However, this healthy immigrant advantage was not found among more recent refugees (HR 0.93, 95% CI 0.81-1.08), immigrants with no previous education (HR 1.08, 95% CI 0.84-1.40), and those who were unmarried (HR 0.80, 95% CI 0.62-1.03). CONCLUSION Immigrants with diabetes are at lower risk for cardiovascular events and mortality compared with long-term residents, an effect that persists more than 10 years after arrival. Not all immigrants demonstrate this health advantage.

Impact of patient-centered discharge tools: A systematic review

BACKGROUND: Patient‐centered discharge tools provide an opportunity to engage patients, enhance patient understanding, and improve capacity for self‐care and postdischarge outcomes. PURPOSE: To review studies that engaged patients in the design or delivery of discharge instruction tools and that tested their effect among hospitalized patients. DATA SOURCES: We conducted a search of 12 databases and journals from January 1994 through May 2014, and references of retrieved studies. STUDY SELECTION: English‐language studies that tested discharge tools meant to engage patients were selected. Studies that measured outcomes after 3 months or without a control group or period were excluded. DATA EXTRACTION: Two independent reviewers assessed the full‐text papers and extracted data on features of patient engagement. DATA SYNTHESIS: Thirty articles met inclusion criteria, 28 of which examined educational tools. Of these, 13 articles involved patients in content creation or tool delivery, with only 6 studies involving patients in both. While many of these studies (10 studies) demonstrated an improvement in patient comprehension, few studies found improvement in patient adherence despite their engagement. A few studies demonstrated an improvement in self‐efficacy (2 studies) and a reduction in unplanned visits (3 studies). CONCLUSIONS: Improving patient engagement through the use of media, visual aids, or by involving patients when creating or delivering a discharge tool improves comprehension. However, further studies are needed to clarify the effect on patient experience, adherence, and healthcare utilization postdischarge. Better characterization of the level of patient engagement when designing discharge tools is needed given the heterogeneity found in current studies.

Co‐creating patient‐oriented discharge instructions with patients, caregivers, and healthcare providers

For hospitalized patients, the transition from hospital to home is frequently accompanied by a significant amount of information to absorb. The objective of this work was to engage patients, caregivers, and healthcare providers in codeveloping patient-oriented discharge instructions, (ie, a brief transition plan with information that patients want). Overseen by a multidisciplinary advisory team, a participatory action approach using mixed methods was employed. Although formal inclusion and exclusion criteria were not used, deliberate efforts were made to engage groups with language barriers and limited health literacy. Symbols were designed and validated with the patient groups to represent each section of information to make the form more understandable for these patients. A prototype was codesigned using an iterative process. The form has been adapted for use in multiple health settings and is currently undergoing a multisite pilot to evaluate its effect on patient and provider experience.

A point prevalence study of urinary catheter use among teaching hospitals with and without reduction programs

Division of General Internal Medicine, Mount Sinai Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Division of Infectious Diseases and General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of General Internal Medicine, University Health Network, Toronto, Canada; Division of General Internal Medicine, McGill University Health Centre, Montreal, Canada; Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada.

Health Literacy Among Surgical Patients: A Systematic Review and Meta-analysis

Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients’ health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7–39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5–39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.

“We are doing it together”; The integral role of caregivers in a patients’ transition home from the medicine unit

Background An admission to hospital for acute illness can be difficult for patients and lead to high levels of anxiety. Patients are given a lot of information throughout their hospital stay and instructions at discharge to follow when they get home. For complex medical patients, the ability to retain, understand, and adhere to these instructions is a critical marker of a successful transition. This study was undertaken to explore factors impacting the ability of patients to understand and adhere to instructions. Methods A qualitative design of interviews with patients and caregivers was used. Participants were adult patients and caregivers with congestive heart failure, chronic obstructive pulmonary disease, or community-acquired pneumonia being discharged home from three academic acute care hospitals in Ontario, Canada. Semi structured interviews were conducted with participants within one week following their discharge from hospital. Interviews were audiotaped and transcribed. Five independent researchers participated in an iterative process of coding, reviewing, and analyzing the interviews using direct content analysis. Results In total, 27 participants completed qualitative interviews. Analysis revealed the role of the caregiver to be critical in its relation to the ability of patients to understand and adhere to discharge instructions. Within the topic of caregiving, we draw on three areas of insight: The first clarified how caregivers support patients after they are discharged home from the hospital. The second highlighted how caregiver involvement impacts patient understanding and adherence to discharge instructions. The third revealed system factors that influence a caregiver’s involvement when receiving discharge instructions. Conclusion Caregivers play an important role in the transition of a complex medical patient by impacting a patient’s ability to understand and adhere to their discharge instructions. The themes identified in this paper highlight opportunities for healthcare providers and institutions to effectively involve caregivers during transitions from acute care hospitals to home.

809-4 Impact of diabetes on 12-month outcomes following coronary artery bypass graft surgery: Results from the routine versus selective exercise treadmill testing after coronary artery bypass grafting (ROSETTA-CABG) registry

Background. To identify the impact of deep strernal wound infection (DSWI) on long-term survival after coronary artery bypass grafting (CABG). Methods. We studied 3760 consecutive patients who underwent isolated CABG between 1992 and 2002. Patients with CABG and no DSWI were compared with those who developed DSWI. Long-term survival data were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for DSWI was determined by logistic regression analysis and each patient with DSWI was then matched to 10 patients without DSWI. Results. Forty patients (1.1%) developed DSWI. Multivariate logistic regression analysis found that the independent predictors of DSWI were diabetes mellitus (odds ratio (OR) 5.5; P<0.001), hemodynamic instability (OR 4.0; P=0.026), use of bilateral internal thoracic arteries (OR 2.6; P=0.010), endocarditis and/or sepsis (OR 29.9; P<0.001) and dialysis (OR 3.4; P=0.049). There were no differences in thirty-day mortality between matched groups. Patients with DSWI had longer length of stay (35.0 versus 16.4 days; P<0.001). Kaplan-Meier curves of the two matched groups are shown in figure. After adjustment for pre, intra and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 2.44 (95%CI 1.51-3.92; P<0.001). Conclusions. We found that DSWI after CABG operations was associated with increased long-term mortality. 11:30 a.m.