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Increasing Hospital Admission Rates for Urological Complications After Transrectal Ultrasound Guided Prostate Biopsy

PURPOSE Transrectal ultrasound guided prostate biopsy is widely used to confirm the diagnosis of prostate cancer. The technique has been associated with significant morbidity in a small proportion of patients. MATERIALS AND METHODS We conducted a population based study of 75,190 men who underwent a transrectal ultrasound guided biopsy in Ontario, Canada, between 1996 and 2005. We used hospital and cancer registry administrative databases to estimate the rates of hospital admission and mortality due to urological complications associated with the procedure. RESULTS Of the 75,190 men who underwent transrectal ultrasound biopsy 33,508 (44.6%) were diagnosed with prostate cancer and 41,682 (55.4%) did not have prostate cancer. The hospital admission rate for urological complications within 30 days of the procedure for men without cancer was 1.9% (781/41,482). The 30-day hospital admission rate increased from 1.0% in 1996 to 4.1% in 2005 (p for trend <0.0001). The majority of hospital admissions (72%) were for infection related reasons. The probability of being admitted to hospital within 30 days of having the procedure increased 4-fold between 1996 and 2005 (OR 3.7, 95% CI 2.0-7.0, p <0.0001). The overall 30-day mortality rate was 0.09% but did not change during the study period. CONCLUSIONS The hospital admission rates for complications following transrectal ultrasound guided prostate biopsy have increased dramatically during the last 10 years primarily due to an increasing rate of infection related complications.

Bleeding and Perforation After Outpatient Colonoscopy and Their Risk Factors in Usual Clinical Practice

BACKGROUND & AIMS The most widely quoted complication rates for colonoscopy are from case series performed by expert endoscopists. Our objectives were to evaluate the rates of bleeding, perforation, and death associated with outpatient colonoscopy and their risk factors in a population-based study. METHODS We identified all individuals 50 to 75 years old who underwent an outpatient colonoscopy during April 1, 2002, to March 31, 2003, in British Columbia, Alberta, Ontario, and Nova Scotia, Canada. Using administrative data, we identified all individuals who were admitted to hospital with bleeding or perforation within 30 days following the colonoscopy in each province. We calculated the pooled rates of bleeding and perforation from the 4 provinces. In Ontario, we abstracted the hospital charts of all deaths that occurred within 30 days following the procedure. We used generalized estimating equations models to evaluate factors associated with bleeding and perforation. RESULTS We identified 97,091 persons who had an outpatient colonoscopy. The pooled rates of colonoscopy-related bleeding and perforation were 1.64/1000 and 0.85/1000, respectively. The death rate was 0.074/1000 or approximately 1/14,000. Older age, male sex, having a polypectomy, and having the colonoscopy performed by a low-volume endoscopist were associated with increased odds of bleeding or perforation. CONCLUSIONS Although colonoscopy has established benefits for the detection of colorectal cancer and adenomatous polyps, the procedure is associated with risks of serious complications, including death. Older age, male sex, having a polypectomy, and having the procedure done by a low-volume endoscopist were independently associated with colonoscopy-related bleeding and perforation.

Introduction of surgical safety checklists in Ontario, Canada.

BACKGROUND Evidence from observational studies that the use of surgical safety checklists results in striking improvements in surgical outcomes led to the rapid adoption of such checklists worldwide. However, the effect of mandatory adoption of surgical safety checklists is unclear. A policy encouraging the universal adoption of checklists by hospitals in Ontario, Canada, provided a natural experiment to assess the effectiveness of checklists in typical practice settings. METHODS We surveyed all acute care hospitals in Ontario to determine when surgical safety checklists were adopted. Using administrative health data, we compared operative mortality, rate of surgical complications, length of hospital stay, and rates of hospital readmission and emergency department visits within 30 days after discharge among patients undergoing a variety of surgical procedures before and after adoption of a checklist. RESULTS During 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% (95% confidence interval [CI], 0.66 to 0.76) before implementation of a surgical checklist and 0.65% (95% CI, 0.60 to 0.70) afterward (odds ratio, 0.91; 95% CI, 0.80 to 1.03; P=0.13). The adjusted risk of surgical complications was 3.86% (95% CI, 3.76 to 3.96) before implementation and 3.82% (95% CI, 3.71 to 3.92) afterward (odds ratio, 0.97; 95% CI, 0.90 to 1.03; P=0.29). CONCLUSIONS Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications. (Funded by the Canadian Institutes of Health Research.).

Trends in the Aggressiveness of End-of-Life Cancer Care in the Universal Health Care System of Ontario, Canada

PURPOSE To describe trends in the aggressiveness of end-of-life (EOL) cancer care in a universal health care system in Ontario, Canada, between 1993 and 2004, and to compare with findings reported in the United States. METHODS A population-based, retrospective, cohort study that used administrative data linked to registry data. Aggressiveness of EOL care was defined as the occurrence of at least one of the following indicators: last dose of chemotherapy received within 14 days of death; more than one emergency department (ED) visit within 30 days of death; more than one hospitalization within 30 days of death; or at least one intensive care unit (ICU) admission within 30 days of death. RESULTS Among 227,161 patients, 22.4% experienced at least one incident of potentially aggressive EOL cancer care. Multivariable analyses showed that with each successive year, patients were significantly more likely to encounter some aggressive intervention (odds ratio, 1.01; 95% CI, 1.01 to 1.02). Multiple emergency department (ED) visits, ICU admissions, and chemotherapy use increased significantly over time, whereas multiple hospital admissions declined (P < .05). Patients were more likely to receive aggressive EOL care if they were men, were younger, lived in rural regions, had a higher level of comorbidity, or had breast, lung, or hematologic malignancies. Chemotherapy and ICU utilization were lower in Ontario than in the United States. CONCLUSION Aggressiveness of cancer care near the EOL is increasing over time in Ontario, Canada, although overall rates were lower than in the United States. Health system characteristics and patient or physician cultural factors may play a role in the observed differences.

Risk of Developing Proximal Versus Distal Colorectal Cancer After a Negative Colonoscopy: A Population-Based Study

BACKGROUND & AIMS The incidence of colorectal cancer (CRC) overall is reduced for up to 10 years after a negative colonoscopy. The objective of this research was to determine the incidence of proximal and distal CRC after a negative complete colonoscopy. METHODS A cohort of Ontario residents aged 50 to 80 years who had a negative complete colonoscopy between January 1, 1992, and December 31, 1997, was identified by using linked administrative databases. Cohort members had no prior history of CRC, inflammatory bowel disease, or recent colonic resection. Each individual was followed up through December 31, 2005, and the relative rate (RR) of overall CRC, distal CRC, and proximal CRC was compared with the remaining Ontario population. RESULTS A cohort of 110,402 individuals with a negative complete colonoscopy was identified. The RR of CRC overall and the RR of distal CRC remained significantly lower than the Ontario population. For example, at year 14 the RR of distal CRC was 0.21 (95% confidence interval, 0.05-0.36). The RR of proximal CRC was significantly lower than the Ontario population in half of the follow-up years, mainly after 7 years of follow-up. CONCLUSIONS Over a 14-year follow-up period, negative complete colonoscopy was associated with a subsequent reduced incidence of CRC overall, and of incident CRC in the distal colon. However, the reduction in incidence of proximal CRC differed in magnitude and timing, and occurred in half the follow-up years, mainly after 7 years of follow-up. These results highlight an important limitation of colonoscopy in usual clinical practice.

Exploring the rising incidence of neuroendocrine tumors: A population-based analysis of epidemiology, metastatic presentation, and outcomes

An increased incidence of neuroendocrine tumors (NETs) has been reported worldwide, but the reasons underlying this rise have not been identified. By assessing patterns of metastatic presentation, this study sought to examine the epidemiologic characteristics of NETs and the contribution of early‐stage detection to the rising incidence.

Endoscopist Specialty Is Associated With Incident Colorectal Cancer After a Negative Colonoscopy

BACKGROUND & AIMS The incidence of colorectal cancer (CRC) is reduced for at least 10 years after a negative colonoscopy, compared with the general population. However, CRCs do occur in individuals after a negative colonoscopy. We investigated whether the colonoscopy volume and specialty of the endoscopists who perform the exam are associated with CRC after a negative complete colonoscopy. METHODS A cohort of Ontario residents, 50-80 years old, who had a negative complete colonoscopy between January 1, 1992, and December 31, 1997, was identified by using linked administrative databases. Cohort members had no history of CRC or inflammatory bowel disease or a recent colonic resection. Each individual was followed through December 31, 2006, and those with a new diagnosis of CRC were identified. Multivariable analysis was used to evaluate the association of patient, endoscopist, and procedure setting characteristics with incident CRC. RESULTS A cohort of 110,402 individuals with a negative complete colonoscopy was identified; the majority (86%) had their procedures performed in hospitals. During the 15-year follow-up period, 1596 (14.5%) developed CRC. There was no association between endoscopist colonoscopy volume and incident CRC. Among persons who had their colonoscopies at a hospital, those who had their procedures performed by a non-gastroenterologist were at significantly increased risk for developing subsequent CRC. CONCLUSIONS Endoscopist specialty is an important determinant of the effectiveness of colonoscopy in usual clinical practice. After a negative colonoscopy, those who have had their procedures performed by a gastroenterologist are less likely to develop CRC.

Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study

BACKGROUND Studies of complications resulting from surgery or radiotherapy for prostate cancer have mainly focused on incontinence and erectile dysfunction. We aimed to assess other important complications associated with these treatments for prostate cancer. METHODS We did a population-based retrospective cohort study, in which we used administrative hospital data, physician billing codes, and cancer registry data for men who underwent either surgery or radiotherapy alone for prostate cancer between 2002 and 2009 in Ontario, Canada. We measured the 5-year cumulative incidence of five treatment-related complication endpoints: hospital admissions; urological, rectal, or anal procedures; open surgical procedures; and secondary malignancies. FINDINGS In the 32 465 patients included in the study, the 5-year cumulative incidence of admission to hospital for a treatment-related complication was 22·2% (95% CI 21·7-22·7), but was 2·4% (2·2-2·6) for patients whose length of stay was longer than 1 day. The 5-year cumulative incidence of needing a urological procedure was 32·0% (95% CI 31·4-32·5), that of a rectal or anal procedure was 13·7% (13·3-14·1), and that of an open surgical procedure was 0·9% (0·8-1·1). The 5-year cumulative incidence of a second primary malignancy was 3·0% (2·6-3·5). These risks were significantly higher than were those of 32 465 matched controls with no history of prostate cancer. Older age and comorbidity at the time of index treatment were important predictors for a complication in all outcome categories, but the type of treatment received was the strongest predictor for complications. Patients who were given radiotherapy had higher incidence of complications for hospital admissions, rectal or anal procedures, open surgical procedures, and secondary malignancies at 5 years than did those who underwent surgery (adjusted hazard ratios 2·08-10·8, p<0·0001). However, the number of urological procedures was lower in the radiotherapy than in the surgery group (adjusted hazard ratio 0·66, 95% CI 0·63-0·69; p<0·0001) INTERPRETATION: Complications after prostate cancer treatment are frequent and dependent on age, comorbidity, and the type of treatment. Patients and physicians should be aware of these risks when choosing treatment for prostate cancer, and should balance them with the clinical effectiveness of each therapy. FUNDING Ajmera Family Chair in Urologic Oncology.

Modeling transmission of methicillin-resistant Staphylococcus aureus among patients admitted to a hospital.

OBJECTIVE To determine the impact of the screening test, nursing workload, handwashing rates, and dependence of handwashing on risk level of patient visit on methicillin-resistant Staphylococcus aureus (MRSA) transmission among hospitalized patients. SETTING General medical ward. METHODS Monte Carlo simulation was used to model MRSA transmission (median rate per 1,000 patient-days). Visits by healthcare workers (HCWs) to patients were simulated, and MRSA was assumed to be transmitted among patients via HCWs. RESULTS The transmission rate was reduced from 0.89 to 0.56 by the combination of increasing the sensitivity of the screening test from 80% to 99% and being able to report results in 1 day instead of 4 days. Reducing the patient-to-nurse ratio from 4.3 in the day and 6.8 at night to 3.8 and 5.7, respectively, reduced the number of nosocomial infections from 0.89 to 0.85; reducing the ratio to 1 and 1, respectively, further reduced the number of nosocomial infections to 0.32. Increases in handwashing rates by 0%, 10%, and 20% for high-risk visits yielded reductions in nosocomial infections similar to those yielded by increases in handwashing rates for all visits (0.89, 0.36, and 0.24, respectively). Screening all patients for MRSA at admission reduced the transmission rate to 0.81 per 1,000 patient-days from 1.37 if no patients were screened. CONCLUSION Within the ranges of parameters studied, the most effective strategies for reducing the rate of MRSA transmission were increasing the handwashing rates for visits involving contact with skin or bodily fluid and screening patients for MRSA at admission.

HER2/neu and Ki-67 expression predict non-invasive recurrence following breast-conserving therapy for ductal carcinoma in situ.

Background:Ductal carcinoma in situ (DCIS) is a non-invasive form of breast cancer that may progress to invasive cancer. Identification of factors that predict recurrence and distinguish DCIS from invasive recurrence would facilitate treatment recommendations. We examined the prognostic value of nine molecular markers on the risks of local recurrence (DCIS and invasive) among women treated with breast-conserving therapy.Methods:A total of 213 women who were treated with breast-conserving therapy between 1982 and 2000 were included; 141 received breast-conserving surgery alone and 72 cases received radiotherapy. We performed immunohistochemical staining on the DCIS specimen for nine markers: oestrogen receptor, progesterone receptor, Ki-67, p53, p21, cyclinD1, HER2/neu, calgranulin and psoriasin. We performed univariable and multivariable survival analyses to identify markers associated with the recurrence.Results:The rate of recurrence at 10 years was 36% for patients treated with breast-conserving surgery alone and 18% for women who received breast-conserving surgery and radiotherapy. HER2/neu+/Ki-67+ expression was associated with an increased risk of DCIS recurrence, independent of grade and age (HR=3.22; 95% CI: 1.47–7.03; P=0.003). None of the nine markers were predictive of invasive recurrence.Conclusion:Women with a HER2/neu/neu+/Ki67+ DCIS have a higher risk of developing DCIS local recurrence after breast-conserving surgery.