Randall Fransoo

Are cervical cancer screening rates different for women with schizophrenia? A Manitoba population-based study

CONTEXT Barriers to cervical cancer screening (Pap tests) may exist for women experiencing schizophrenia. DESIGN This study analyzed healthcare records of all women in the province of Manitoba, Canada to: (a) compare cervical cancer screening rates of women with and without schizophrenia; and (b) determine factors associated with screening uptake. SETTING This study took place in Manitoba, Canada, utilizing anonymized universal administrative data in the Population Health Research Data Repository at the Manitoba Centre for Health Policy. PARTICIPANTS All females aged 18-69 living in Manitoba December 31, 2002, excluding those diagnosed with invasive or in situ cervical cancer in the study period or previous 5 years. MAIN OUTCOME To determine factors associated with Papanicolaou (Pap) test uptake (1+ Pap test in 3 years, 2001/02-2003/04), logistic regression modeling included: diagnosis of schizophrenia, age, region, average household income, continuity of care (COC), presence of major physical comorbidity. Good COC was defined as at least 50% of ambulatory physician visits from the same general/family practitioner within two years. RESULTS Women with schizophrenia (n=3220) were less likely to have a Pap test (58.8% vs. 67.8%, p<.0001) compared to all other women (n=335 294). In the logistic regression, a diagnosis of schizophrenia (aOR=0.70, 95% CI 0.65-0.75); aged 50+, and living in a low-income area or the North decreased likelihood; good continuity of care (aOR 1.88, 95% CI 1.85-1.91) and greater physical comorbidity (1.21, 95% CI 1.04-1.41) increased likelihood. CONCLUSION Women with schizophrenia are less likely to receive appropriate cervical cancer screening. Since good continuity of care by primary care physicians may mitigate this, psychiatrists should consider assisting in ensuring screening uptake.

Does a diagnosis of schizophrenia reduce rates of mammography screening? A Manitoba population-based study

1. IntroductionIt is estimated that mammography screening can reducemortality from breast cancer by 20 –35% for women aged 50 to69years,and20%forwomenaged40through49years( Elmoreetal.;2005;FletcherandElmore2003 ).Forwomenaged50 –69,theCanadian Task Force on the Periodic Health Examination (nowknownastheCanadianTaskForceonPreventiveHealthCare)andthe U.S. Preventive Services Task Force recommend mammo-graphyscreeningevery1 –2years(deGrasseetal.,1999;Ferrinietal.,1996; Ringash and Canadian Task Force on Preventive HealthCare, 2001; US Preventive Services Task Force 2002 ). ManitobasBreastScreeningProgramstatesthatthebestchancesofreducingdeaths from breast cancer arise from screening at least 70% ofManitoba women aged 50 through 69 every two years.According to the Statistics Canada Canadian CommunityHealth Survey [CCHS] 3.1 (Statistics Canada 2005) 72.6% ofwomen aged 50 through 69 years received a mammogram(screening or diagnostic) over a two-year period. Women inManitoba self-reported much lower rates, at 65.6%, with 42.6%

Epidemiology of critically ill patients in intensive care units: a population-based observational study

IntroductionEpidemiologic assessment of critically ill people in Intensive Care Units (ICUs) is needed to ensure the health care system can meet current and future needs. However, few such studies have been published.MethodsPopulation-based analysis of all adult ICU care in the Canadian province of Manitoba, 1999 to 2007, using administrative data. We calculated age-adjusted rates and trends of ICU care, overall and subdivided by age, sex and income.ResultsIn 2007, Manitoba had a population of 1.2 million, 118 ICU beds in 21 ICUs, for 9.8 beds per 100,000 population. Approximately 0.72% of men and 0.47% of women were admitted to ICUs yearly. The age-adjusted, male:female rate ratio was 1.75 (95% CI 1.64 to 1.88). Mean age was 64.5 ± 16.4 years. Rates rose rapidly after age 40, peaked at age 75 to 80, and declined for the oldest age groups. Rates were higher among residents of lower income areas, for example declining from 7.9 to 4.4 per 100,000 population from the poorest to the wealthiest income quintiles (p <0.0001). Rates of ICU admission slowly declined over time, while cumulative yearly ICU bed-days slowly rose; changes were age-dependent, with faster declines in admission rates with older age. There was a high rate of recidivism; 16% of ICU patients had received ICU care previously.ConclusionsThese temporal trends in ICU admission rates and cumulative bed-days used have significant implications for health system planning. The differences by age, sex and socioeconomic status, and the high rate of recidivism require further research to clarify their causes, and to devise strategies for reducing critical illness in high-risk groups.

Dementia and depression with ischemic heart disease: a population-based longitudinal study comparing interventional approaches to medical management.

Background We compared the proportion of ischemic heart disease (IHD) patients newly diagnosed with dementia and depression across three treatment groups: percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical management alone (IHD-medical). Methods and Findings De-identified, individual-level administrative records of health service use for the population of Manitoba, Canada (approximately 1.1 million) were examined. From April 1, 1993 to March 31, 1998, patients were identified with a diagnosis of IHD (ICD-9-CM codes). Index events of CABG or PCI were identified from April 1, 1998 to March 31, 2003. Outcomes were depression or dementia after the index event. Patients were followed forward to March 31, 2006 or until censored. Proportional hazards regression analysis was undertaken. Independent variables examined were age, sex, diabetes, hypertension and income quintile, medical management alone for IHD, or intervention by PCI or CABG. Age, sex, diabetes, and presence of hypertension were all strongly associated with the diagnosis of depression and dementia. There was no association with income quintile. Dementia was less frequent with PCI compared to medical management; (HR = 0.65; p = 0.017). CABG did not provide the same protective effect compared to medical management (HR = 0.90; p = 0.372). New diagnosis depression was more frequent with interventional approaches: PCI (n = 626; hazard ratio = 1.25; p = 0.028) and CABG (n = 1124, HR = 1.32; p = 0.0001) than non-interventional patients (n = 34,508). Subsequent CABG was nearly 16-fold higher (p<0.0001) and subsequent PCI was 22-fold higher (p<0.0001) for PCI-managed than CABG-managed patients. Conclusions Patients managed with PCI had the lowest likelihood of dementia—only 65% of the risk for medical management alone. Both interventional approaches were associated with a higher risk of new diagnosed depression compared to medical management. Long-term myocardial revascularization was superior with CABG. These findings suggest that PCI may confer a long-term protective effect from dementia. The mechanism(s) of dementia protection requires elucidation.

A Population-Based Observational Study of Intensive Care Unit–Related Outcomes. With Emphasis on Post-Hospital Outcomes

RATIONALE Many studies of critical illness outcomes have been restricted to short-term outcomes, selected diagnoses, and patients in one or a few intensive care units (ICUs). OBJECTIVES Evaluate a range of relevant outcomes in a population-based cohort of patients admitted to ICUs. METHODS Among all adult residents of the Canadian province of Manitoba admitted to ICUs over a 9-year period, we assessed ICU, hospital, 30-day, and 180-day mortality rates; ICU and hospital lengths-of-stay; Post-hospital use of hospital care, ICU care, outpatient physician care, medications, and home care; and Post-hospital residence location. We explored data stratified by age, sex, and separate categories of geocoded income for urban and rural residents. For Post-hospital use variables we compared ICU patients with those admitted to hospitals without the need for ICU care. MEASUREMENTS AND MAIN RESULTS After ICU admission there was a high initial death rate, which declined between 30 and 180 days and thereafter remained at the lower value. Hospital mortality was 19.0%, with 21.7% dying within 6 months of ICU admission. Women had higher hospital mortality than men (20.8 vs. 17.8%; P = 0.0008). Among urban residents there was a steady gradient of declining hospital mortality with rising income (P < 0.0001). Mean ICU length of stay was 3.96 days, increasing 0.11 d/yr over the study period (P = 0.001); median ICU length of stay was 2.33 days and did not change over time. In the year after ICU care, 41% were rehospitalized, 10% were readmitted to an ICU, 98% had outpatient physician visits, 96% used prescription medications, and 27% used home care services. Although most of these parameters were statistically higher than for hospitalizations not requiring ICU care, differences were generally small. Among hospital survivors, 2.7% were discharged to chronic care facilities, with 2.5% living in such facilities 3 months later. CONCLUSIONS Post-hospital medical resource use among ICU survivors is substantial, although similar to that after non-ICU hospitalization. Although the fraction of survivors unable to live independently was small, a larger fraction required home care services. Identifying Post-hospital supports needed by ICU survivors can be useful for policy makers and others responsible for healthcare planning.

Increased Incidence of Critical Illness Among Patients With Inflammatory Bowel Disease: A Population-Based Study

BACKGROUND & AIMS Little is known about how often, and for what reasons, patients with inflammatory bowel diseases (IBD) are admitted to the intensive care unit (ICU). We compared incidences of ICU admission, characteristics of critical illness, and mortality after ICU admission between patients with IBD and the general population. METHODS We identified all persons with IBD in the province of Manitoba using a validated administrative definition of IBD for the period from 1984 to 2010. Cases were considered incident for IBD if their first health system contact for IBD was in 1989 or later. We identified a population-based control group, matched by age, sex, and geography (based on postal code). Case and control cohorts were linked to the Manitoba ICU database. We compared outcomes between groups using age- and sex-standardized rates, Cox proportional hazards models, and logistic regression models, adjusting for age, sex, comorbidity, and socioeconomic status. RESULTS There were 8224 prevalent and 4580 incident cases of IBD. After adjustment, the risk for ICU admission was higher for patients with IBD than controls (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.58-2.02). The risk of ICU admission was higher for patients with Crohns disease (HR, 2.31; 95% CI, 1.95-2.75) than ulcerative colitis (HR, 1.37; 95% CI, 1.13-1.65). From 2000 through 2010, age- and sex-standardized annual incidence rates for ICU admission in the prevalent IBD cohort ranged from 0.55% to 1.12%. Compared with controls admitted to ICUs, 1 year after ICU admission, mortality was 32% among patients with IBD. CONCLUSIONS Patients with IBD have a higher risk for admission to the ICU than the general population, and increased mortality 1 year after admission. These findings underscore the potential severity of IBD.

Not as skinny as we used to think: Body mass index in children and adolescents at diagnosis of type 1 diabetes mellitus

This retrospective analysis of clinical data for children (2-18 years old) with incident T1D found surprisingly low (9%) prevalence of underweight, and high (15% overweight; 8% obesity) respectively at diagnosis. These results suggests a need to rethink the classic clinical teaching surrounding skinnier presentation at diagnosis, and importantly, the corresponding expectation of weight gain after insulin therapy initiation.

Is the change in body mass index among children newly diagnosed with type 1 diabetes mellitus associated with obesity at transition from pediatric to adult care

Insulin therapy is lifesaving treatment for individuals with type 1 diabetes (T1D). Its initiation maybe associated with significant weight gain because of change from a catabolic to an anabolic state. Excessive weight‐gain increases the risk of obesity and is associated with chronic disease.

Health care utilization before and after intensive care unit admission in multiple sclerosis

OBJECTIVES The incidence of intensive care unit (ICU) admission is elevated in the multiple sclerosis (MS) population but the reasons for this are incompletely understood, as are outcomes post-ICU admission. Among MS patients we examined the association between ICU admission and health care utilization in the year preceding admission, and compared health care utilization following ICU admission among persons with MS and persons from the general population. METHODS We used population-based administrative data from Manitoba, Canada to identify 4237 MS cases of which 2547 were incident. We compared the incidence rates of ICU admission in the prevalent MS population according to health care utilization in the year before admission, adjusting for age, sex, comorbidity and socioeconomic status. Among incident cases of MS we compared rates of health care utilization after ICU admission to those in a matched general population cohort. We used generalized linear models adjusting for age, sex, socioeconomic status, region, comorbidity and utilization before admission. RESULTS Of 4219 prevalent MS cases, 222 (5.3%) were admitted to the ICU. After adjustment, any hospitalization in the prior year conferred an 80% increased incidence, and physician visits in the highest tertile and prescription costs in the highest quartile in the prior year each conferred a more than two-fold increased incidence of admission. Among 2547 incident cases of MS, 109 (4.3%) were admitted to the ICU and 93 survived their admission. Thirty-eight percent of the MS population were re-hospitalized in the year following admission, similar to the matched population (33.8%). Seven percent of both populations were readmitted to the ICU. The MS population had more hospital days after ICU admission than the matched population (adjusted RR 3.11; 95% CI: 1.34-5.90). After adjustment the number of physician visits did not differ between populations. CONCLUSIONS The incidence of ICU admission is higher among persons with MS who have higher prior health care utilization. Health care utilization remains high after ICU admission. Efforts to prevent ICU admission in this population are needed.

A Simple Effective Protocol to Increase Prenatal Detection of Critical Congenital Heart Disease

Prenatal diagnosis of congenital heart disease (CHD) during routine obstetric sonography has been aptly named the sonographer’s Achilles heel. Although CHD occurs more commonly than any other major congenital abnormality, the detection rate remains low. The goal of this study was to improve the prenatal diagnosis of CHD during routine obstetric sonography through the development and implementation of a simple and effective screening protocol.