Neil R. Bell

Recommendations on screening for cervical cancer

cervical cancer were diagnosed in Canada, with about 350 deaths. The number of cases of diagnosed cervical cancer in creases among women aged 25 years and older, peaking during the fifth decade of life (Figure 1). The incidence of and mortality due to cervical cancer in Canada have decreased substantially in the past 50 years, and long-term survival rates after treatment are high. Lifetime incidence was 1.5% in 1972, and is now 0.7%; risk of death from cervical cancer is now 0.2%. Most advanced cervical cancer (and associated mortality) occurs among women who have never undergone screening or who have had a long interval between Papanicolaou (Pap) tests. Screening for cervival cancer using the Pap test detects precursor lesions, thereby allowing earlier and potentially less invasive treatment than is re quired for disease that causes symptoms. The benefits of such screening on the incidence of invasive disease and death due to cervical cancer have been consistently shown in cohort and case–control studies. It is likely that much of the change seen in the incidence of cervical cancer in Canada is due to screening, but early and frequent (often annual) cervical screening is unnecessary: other countries have achieved similar outcomes with less frequent testing and starting screening at older ages. The similar levels of success with different approaches highlights uncertainties regarding the best ages at which to start and stop screening, screening intervals and screening methods. Furthermore, the benefits of screening must be balanced against its potential harms, such as additional follow-up tests for abnormal results and unnecessary treatment (e.g., owing to false -positives and overdiagnosis). The likelihood of abnormal Pap test results is highest for young women, and decreases with increasing age. Because the prevalence of highgrade abnormalities declines steadily with age, al though the incidence of cancer is higher, the proportion of abnormal results that represent serious abnormalities is greater among older women. Women whose initial Pap test result is abnormal may be asked to undergo a repeat test or have a colposcopy. The colposcopist may then biopsy the cervix. If the biopsy shows cervical intra epithelial neoplasia, the colposcopist may then treat the cervix by excising the transformation zone using various methods. These procedures cause short-term pain, bleeding and discharge, and may cause early loss of future pregnancies or premature labour. It is likely that many of these procedures can be considered overtreatment, because fewer than one-third of even high-grade abnormalities progress to cancer. This guideline provides updated recommendations for screening for cervical cancer in Canada based on new information about the epidemiology and diagnosis of cervical cancer and a new systematic search of the literature. This guideline updates the recommendations of the Canadian Task Force on Preventive Health Care that were last revised in 1994. Recommendations are presented for the use of Pap tests for women with no symptoms of cervical cancer who are or who have been sexually active, regardless of sexual orientation. Separate recommendations are provided for screening in women in the following age categories: younger than 20 years, 20–24 years, 25–29 years, 30– 69 years and 70 years or older. Re com mend ations Recommendations on screening for cervical cancer

Recommendations on screening for type 2 diabetes in adults.

ans (6.8%) had either type 1 or type 2 diabetes, and an additional 480 000 (1.4%) were unaware that they were affected. The most recent Canadian data indicate that, from 1998/99 to 2008/09, the prevalence of diagnosed diabetes increased by 70% (Figure 1). The greatest relative increase in prevalence was seen in the age groups 35–39 and 40–44 years, in which the proportion doubled. In 2008/09, almost 50% of people with newly diagnosed diabetes were 45–64 years old (Figure 2). Substantial increases in prevalence are projected over the next decade. Because type 1 diabetes is much less common than type 2 diabetes and is generally symptomatic, we focused on type 2 diabetes in these guidelines. Laboratory values used to define the diagnosis of diabetes have become more inclusive over time (Appendix 1). In 2002, a new diagnostic category (now commonly known as prediabetes) was created to describe patients at very high risk of diabetes. More recently, glycated hemoglobin (herein referred to as A1C), which reflects an individual’s average plasma glucose level over the previous 2–3 months, has been accepted as an alternative diagnostic test for type 2 diabetes. Long-term consequences of type 2 diabetes include microvascular (retinopathy, nephropathy, neuropathy) and macrovascular (stroke, myocardial infarction) complications. An estimated 65%–80% of people with diabetes will die of a cardiovascular event, many without prior signs or symptoms of cardiovascular disease. Type 2 diabetes is a prevalent and costly chronic illness that demands lifestyle interventions, effective monitoring and pharmacologic management. Management of risk factors, including physical inactivity, blood pressure and blood lipid levels as well as blood glucose levels, is required to prevent long-term complications. Uncertainties remain about how best to prevent diabetes, the relative benefits of population screening and risk assessment, the ideal frequency of screening in high-risk populations and the potential harms of screening. This document updates the 2005 Canadian Task Force on Preventive Health Care recommendations on screening asymptomatic adults for type 2 diabetes. It does not apply to people with symptoms of diabetes or those who are at risk of type 1 diabetes.

The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study

PURPOSE To examine the relation between follow-up office visits after emergency discharge and the risk of emergency readmissions in patients with asthma or chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS We used population-based data to identify all patients in Alberta, Canada, who had at least one emergency visit for asthma or COPD between April 1, 1996, and March 31, 1997 (N = 25 256). A Cox proportional hazards model was used to estimate the adjusted relative risk (RR) of a repeat visit to an emergency department within 90 days of an initial emergency visit in patients who did or did not have an office follow-up within the first 30 days. RESULTS There were 7829 patients (31%) who had an office visit during the 30 days after their initial emergency encounter. Follow-up visits were associated with a significant reduction in the 90-day risk of an emergency readmission (RR = 0.79; 95% confidence interval [CI]: 0.73 to 0.86). Sensitivity analyses showed that a follow-up visit was inversely associated with a repeat emergency visit after adjusting for age, sex, area of residence, and income. CONCLUSION Although these data should be interpreted with caution because of missing information on factors such as quality of care, they suggest that follow-up office visits are effective in reducing early relapses in patients who have been recently treated in emergency departments for asthma or COPD.

Recommendations on screening for prostate cancer with the prostate-specific antigen test

See related commentary on page [1201][1] and at [www.cmaj.ca/lookup/doi/10.1503/cmaj.141252][2] Prostate cancer is the most commonly diagnosed non–skin cancer in men and the third leading cause of cancer-related death among men in Canada.[1][3] The current estimated lifetime risk of diagnosis is

Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care

The prevalence of obesity in adults has increased worldwide and has almost doubled in Canada, from 14% in 1978/79[1][1] to 26% in 2009–2011,[2][2] with 2% of men and 5% of women having a body mass index (BMI) score greater than 40 (Appendix 1, available at [www.cmaj.ca/lookup/suppl/doi:10.1503/

Osteoporosis Case Manager for Patients With Hip Fractures: Results of a Cost-effectiveness Analysis Conducted Alongside a Randomized Trial

BACKGROUND In a randomized trial of patients with hip fractures, we previously demonstrated that a hospital-based case manager could increase rates of appropriate osteoporosis treatment to 51% compared with 22% for usual care (P < .001). Alongside that trial, we conducted an economic analysis. METHODS Patients with hip fractures were randomized to usual care (n = 110) or a case manager (n = 110) and followed up for 1 year. Time-motion studies were used to determine intervention costs. From a third-party health care payer perspective and over the patients remaining lifetime, a Markov decision-analytic model was constructed to determine cost-effectiveness of the intervention compared with usual care. Costs and benefits were discounted at 3% and expressed in 2006 Canadian dollars. RESULTS The intervention cost CaD

Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care

56 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients case managed, 6 fractures (4 hip fractures) were prevented, 4 quality-adjusted life-years were gained, and CaD

Facilitated bone mineral density testing versus hospital‐based case management to improve osteoporosis treatment for hip fracture patients: Additional results from a randomized trial

260 000 was saved by the health care system. Irrespective of the number of patients case managed, the intervention reached a break-even threshold within 2 years. The intervention dominated usual care over the entire spectrum of 1-way sensitivity analyses and was cost-saving in 82% of probabilistic model simulations. CONCLUSIONS Compared with usual care, we found that using a case manager for patients with hip fractures increased rates of appropriate osteoporosis treatment. The intervention dominated usual care, and the analysis suggests that systems implementing an intervention similar to ours should expect to see a reduction in fractures, gains in life expectancy, and substantial cost savings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00175175.

Recommendations on screening for lung cancer.

The prevalence of obesity in Canadian children has risen dramatically from the late 1970s, more than doubling among both boys and girls.1 Based on growth curves generated by the World Health Organization, the prevalence of overweight and obesity in Canadian children aged 2 to 17 years in 2004 was about 35%.1,2 More recent estimates from 2009 to 2011 based on measured weight and height for children aged 5 to 17 years suggest that 32% are overweight (20%) or obese (12%), with the prevalence of obesity almost twice as high in boys (15%) than in girls (8%)3 (Appendix 1, available at www.cmaj.ca/lookup/suppl /doi :10.1503/cmaj.141285/-/DC1). Studies suggest that excess weight in children often persists into adulthood.4–6 Childhood obesity is associated with an increased risk of cardiovascular disease and diabetes in adolescence7 and later in life.8,9 It is now recognized that obesity is a complex problem that will require action from multiple sectors and “systems thinking.”10 Within primary care, the chronic disease model has been proposed as a framework for managing obesity, supporting children and families to manage body weight over time.10 For childhood obesity, the complexity may include parents’ knowledge, parenting style and the family activity environment.11 Whereas options for management of childhood obesity include behavioural, pharmacologic and surgical approaches offered or referred by primary care,10 it is recognized that interventions must be familycentred and may involve services delivered by an interdisciplinary team.11 The 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children provided recommendations for the prevention and management of obesity in Canadians of all ages.12 The last task force guidance specifically on childhood obesity was in 1994; it focused on screening for and treatment of obesity in children, but did not address primary prevention.13 The current guideline provides recommendations for growth monitoring and prevention of overweight and obesity in healthy-weight children and adolescents aged 17 years and younger in primary care settings, and guidance for primary care practitioners on the effectiveness of overweight and obesity management in children and youth aged 2 to 17 years.

Trends in prostate cancer incidence and mortality in Canada during the era of prostate-specific antigen screening

OBJECTIVE We previously demonstrated that a case manager intervention improved osteoporosis (OP) treatment within 6 months of hip fracture compared with usual care. The second phase of the randomized trial compared a less intensive intervention, facilitated bone mineral density (BMD) testing, with usual care and the case manager intervention. METHODS We initially randomized 220 hip fracture patients to either an OP case manager intervention or usual care. After completing the original trial at 6 months postfracture, usual care patients were reallocated to facilitated BMD testing; BMD tests were arranged and results sent to primary care physicians. Main outcomes (bisphosphonate treatment, BMD tests, receipt of appropriate care) were reascertained 1 year following hip fracture and compared with outcomes achieved by the OP case manager intervention and usual care. RESULTS Compared with usual care, facilitated BMD testing increased testing from 29% to 68% (P < 0.001), bisphosphonate use from 22% to 38% (P < 0.001), and receipt of appropriate care from 26% to 45% (P < 0.001). The more intensive (70 versus 30 minutes) and expensive (