Pharmacologic treatment of type 2 diabetes mellitus (T2DM) follows a stepwise approach. Typically, metformin monotherapy is first-line treatment, followed by other noninsulin antihyperglycemic agents ...(NIAHAs) or progression to insulin if glycated hemoglobin (A1C) targets are not achieved. We aimed to describe real-world patterns of basal insulin initiation in people with T2DM, and A1C not at target despite treatment with at least 2 NIAHAs.
A retrospective cohort study was conducted using administrative health data from Alberta, Canada, among adults with T2DM, indexed on the first test with 7.0% < A1C < 9.5% (April 1, 2011 to March 31, 2019), with at least 2 previous NIAHAs but no insulin. Kaplan–Meier (KM) methodology was used to analyze time to basal insulin initiation, with stratification by index A1C. Annual patient status was categorized into 5 groups: basal insulin initiation, death, NIAHA intensification, no change in therapy (subgroups of A1C <7.1% and A1C ≥7.1% clinical inertia), or discontinuance.
The cohort included 14,083 individuals. The KM cumulative probability of initiating basal insulin was 7.7% (95% confidence interval CI 7.3% to 8.2%) at 1 year, increasing to 43.1% (95% CI 42.1% to 44.1%) at 8 years of follow-up. Higher A1C levels were associated with greater proportions of basal insulin initiation. By year 8, proportions with NIAHA intensification and clinical inertia were 12.1% and 19.3%, respectively, relative to year 7.
Despite current clinical practice guidelines recommending achieving A1C targets within 6 months, less than half of the individuals with T2DM and clear indications for basal insulin initiated treatment within 8 years. Efforts to reduce delays in basal insulin initiation are needed.
Le traitement pharmacologique du diabète de type 2 (DT2) se fait selon une approche progressive. Généralement, la metformine en monothérapie est le traitement de première intention, suivi par d'autres agents antihyperglycemiants non insuliniques (AAHNI) ou par un passage à l'insuline si les objectifs d'hémoglobine glyquée A1c (A1C) ne sont pas atteints. Nous avons pour objectif de décrire les modalités d'initiation de l'insuline basale en situation réelle chez les personnes atteintes de DT2 et dont l'A1c n'a pas atteint l'objectif malgré un traitement par ≥2 AAHNI.
Une étude de cohorte rétrospective a été menée à partir des données administratives de santé de l'Alberta, au Canada, chez les adultes atteints de DT2, indexés sur le premier test avec 7.0%<A1C<9.5% (du 1er avril 2011 au 31 mars 2019), avec ≥2 AAHNI prescrits antérieurement mais sans insuline. La méthode d'estimation de Kaplan-Meier (KM) a été utilisée pour analyser le délai d'initiation à l'insuline basale, avec une stratification par indice A1C. Le statut annuel des patients a été classé en cinq groupes: initiation de l'insuline basale, décès, intensification des AAHNI, pas de changement de traitement thérapeutique (sous-groupes A1C<7.1% et A1C≥7.1% (inertie clinique)), ou arrêt du traitement.
La cohorte comprenait 14,083 personnes. La probabilité cumulative estimée par KM d'initier une insuline basale était de 7.7% (Indice de Confiance à 95% (IC 95%): 7.3-8.2%) à 1 an, et passait à 43.1% (IC 95%: 42.1-44.1%) à 8 ans de suivi. Des taux d'A1C plus élevés ont été associés à des proportions plus importantes d'initiation à une insuline basale. À la 8ème année, les proportions de patients ayant bénéficiés d'une intensification des AAHNI et présentant une inertie clinique étaient respectivement de 12.1% et de 19.3% par rapport à la 7ème année.
Malgré les recommandations actuelles des lignes directrices de pratique clinique visant à atteindre les objectifs d'A1C dans les six mois, moins de la moitié des personnes atteintes de DT2 et ayant des indications claires pour une insuline basale ont commencé le traitement dans les 8 ans. Des efforts sont nécessaires pour réduire les retards dans l'initiation de l'insuline basale.
Child Health and Young Adult Outcomes Currie, Janet; Stabile, Mark; Manivong, Phongsack ...
The Journal of human resources,
07/2010, Letnik:
45, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Research has shown a strong connection between birth weight and future outcomes. We ask how health problems after birth affect outcomes using data from public health insurance records for 50,000 ...children born between 1979 and 1987 in the Canadian province of Manitoba. We compare children to siblings born an average of three years apart. We find that health problems in early childhood are significant predictors of young adult outcomes. Early physical health problems are linked to outcomes primarily because they predict later health. Early mental health problems have additional predictive power even conditional on future health and health at birth.
Child Health and Young Adult Outcomes Currie, Janet; Stabile, Mark; Manivong, Phongsack ...
The Journal of human resources,
2010, Letnik:
45, Številka:
3
Journal Article
OBJECTIVES:
To evaluate the impact of changes in cigarette taxes on smoking for youths aged 15–18 in Canada during the time of the Federal Tobacco Control Strategy (FTCS).
METHODS:
We used a ...difference-in-differences framework and leveraged the variation in cigarette taxes across Canada and over time. We used regression models with province and year fixed effects, and individual-level and provincial-level covariates on 2002–2012 data from the Canadian Tobacco Use Monitoring Survey.
RESULTS:
Tax increases generally did not affect smoking outcomes. Each increase of CAD $1.00 (adjusted to year 2000 dollars) in excise cigarette taxes per package of 20 was associated with a 0.2 percentage point (95% CI: −1.8; 2.2) change in smoking prevalence, and a change of 0.3 in mean cigarettes smoked in the past week (95% CI: −1.2; 1.8).
CONCLUSION:
From 2002 to 2012, smoking prevalence and mean smoking frequency were in steady decline among youths in Canada. This decline, however, was evident even among provinces with stable or decreasing cigarette tax levels. Tobacco taxes have mostly increased since the 1980s, and so, tax levels were already quite high by the launch of the FTCS. Province fixed effects and common temporal changes accounted for 83.7% of the variation in smoking prevalence. We derived similar results for smoking frequency. The cumulative tax increase during our study period was at least $1.00 for only three provinces. Thus, our findings suggest that factors driving down tobacco use among youths in all provinces appear to outweigh any impact of small tax increases at already high tax levels.
Severe acute exacerbations of COPD (AECOPDS) are key events that drive health care resource use (HCRU) and negatively impact patients’ quality of life.
What is the real-world burden of COPD relative ...to patients’ medication history, specifically, exposure to short-acting β-agonists (SABAs), antibiotics, and oral corticosteroids (OCSs)?
A population-based retrospective cohort study was conducted of patients in Alberta, Canada, identified as having COPD based on administrative health care data (April 1, 2011-March 31, 2019). The risk of severe AECOPDs over 90 days (COPD events resulting in hospitalization or ED visits) and COPD-specific HCRU were studied relative to prior-year SABA, antibiotic, and OCS history.
One hundred eighty-eight thousand nine hundred sixty-nine patients identified with COPD were identified (mean ± SD age, 68.8 ± 13.0 years). After controlling for age, sex, calendar year at index, comorbidities at index, and prior severe AECOPDs, patients with frequent SABA, antibiotic, or OCS exposure in a given year showed significantly higher 90-day risks of severe AECOPDs in a positively associated relationship. Patients with the highest SABA exposure (≥ 6 canisters in a given year) showed twice the rate of severe AECOPDs as patients with 1 SABA canister (incidence rate ratio IRR, 2.06; 95% CI, 2.01-2.11). The 90-day rates of severe AECOPDs were 51% higher for patients with ≥ 6 vs 1 to 2 antibiotic dispensations (IRR, 1.51; 95% CI, 1.48-1.55) and 3% higher for patients with ≥ 6 vs 1 to 5 OCS burst days (IRR, 1.03; 95% CI, 1.00-1.06). Mean annualized rates of hospitalization and ED visits were highest for patients dispensed ≥ 6 (vs fewer) SABA canisters or antibiotics and patients with any OCS burst days in a given year.
Histories of frequent or prolonged exposure to SABAs, antibiotics, or OCSs were associated with higher rates of severe AECOPDs and HCRU.
Background: Various tobacco control laws and strategies have been implemented in Canada since the 1980s. Excise tobacco taxes are a common form of tobacco control, and tax levels in Canada have been ...gradually increasing since the 1980s. More recently, the Federal Tobacco Control Strategy (FTCS) was launched in 2001 as a planned 10-year initiative by Health Canada (HC), in partnership with Public Health Agency of Canada (PHAC) and other agencies. Two key components of the FTCS were the enforcement of the Tobacco Act and the promotion of smokefree laws. The Tobacco Act is a set of Canadian laws passed in 1997 that includes tobacco control measures such as restrictions on the manufacture and sale, access, and promotion of tobacco products.We can summarize the FTCS goals as the following: (i) prevention of smoking among youths, (ii) cessation and reduction of consumption among smokers, and (iii) protection of nonsmokers from environmental tobacco smoke. Although both smoking prevalence and smoking frequency have declined during the time of the FTCS, the contributions of the various tobacco control strategies in effect in achieving FTCS goals are unclear.Moreover, there exists a socioeconomic gap in smoking among the adult population, and it is also unclear what impact tobacco control strategies operating during the time of the FTCS have had on this gap. If agencies such as Health Canada and the Public Health Agency of Canada are motivated to not only lower overall smoking levels, but to reduce the socioeconomic gap in smoking, then tobacco control strategies must have the greatest effect on the least educated where smoking rates remain highest in Canada.Objectives: The three studies of my PhD dissertation are motivated by the set of FTCS goals and the socioeconomic inequality in smoking. The first one evaluated the effectiveness of cigarette taxes as a tool for the prevention of smoking and the development of a habit among youths. The second study assessed the effectiveness of cigarette taxes in facilitating smoking cessation, and reducing smoking frequency among adults. The third study evaluated the protective effect of smoke-free legislation, but assessed smoking prevalence and frequency on the adult Canadian population. The second and third studies also included an evaluation of the potential differential effects by education.Results: For our analyses, we used the Canadian Tobacco Usage Monitoring Survey 2002–2012 database and exploited the variation in excise cigarette tax levels and implementation of smokefree legislation among the provinces. We used regression models with province and year fixed effects, individual-level covariates, and provincial-level covariates.For Research Objective 1, changes in excise cigarette taxes yielded negligible contributions to the reduction in smoking behaviour among youths. For an increase of $1.00 in excise cigarette taxes per package of 20, the marginal effect was 0.2 (95% CI: –1.8, 2.2) percentage points for smoking prevalence, and 0.3 (95% CI: –1.2, 1.8) cigarettes for smoking frequency (past-week).We obtained similar results for the average effect of taxes on smoking behaviour among adults for Research Objective 2. For an increase of $1.00 in excise cigarette taxes per package of 20, the marginal effect was -0.1 (95% CI: –1.7, 1.5) percentage points for smoking prevalence, and –0.1 (95% CI: –1.9, 1.7) cigarettes (per week) for smoking frequency. We continued to derive null results when assessing the impact of excise cigarette taxes by education for both smoking outcomes.Likewise, for Research Objective 3, provincial smoke-free legislation (PSFL) had little impact on smoking behaviour among adults. The marginal average effect for smoking prevalence was 0.1 (95% CI: –1.3, 1.4) percentage points. The marginal average effect for smoking frequency was –0.6 (95% CI: –2.2, 1.0) cigarettes. Again, we derived null results when assessing the impact of PSFL by education for both smoking outcomes.Conclusions: Although both excise tobacco taxes and smoke-free legislation have the potential to reduce tobacco consumption, their effectiveness appears sensitive to the current anti-tobacco control environment. During the time of the FTCS, there was a much higher level of tobacco control compared to the time prior to its launch and higher compared to other countries. Excise cigarette taxes have been gradually increasing since the 1980s, and so, tax levels were already quite high by the launch of the FTCS. Moreover, taxes and smoke-free legislation had to work in conjunction with other forms of tobacco control such as the Tobacco Act, point-of-sale restrictions, and the enforcement of graphic warning labels on cigarette packages.From 2002–2012, both smoking prevalence and mean smoking frequency have been in steady decline in Canada. These declines, however, are present even in provinces with stable or decreasing cigarette tax levels and for provinces which implement smoke-free legislation at a later time, suggesting that other factors common to all provinces such as growing anti-smoking sentiment have had a greater influence over tobacco use.
This paper explores the relative importance of social factors and health measures in predicting educational achievement in early and late adolescence using population-based administrative data. The ...sample was made up of 41,943 children born in Manitoba, Canada between 1982 and 1989 and remaining in the province until age 18. Multilevel modeling nests each individual (level 1) within a family (level 2) residing within a neighborhood (level 3). Most important in predicting adolescent achievement were a broad socioeconomic status index (and a narrower measure of household income), being on social assistance, mother's age at first birth, gender, residential mobility, the presence of ADHD/Conduct disorders, and measures of family functioning (child taken into care or offered protection services and family structure history). Family size, birth order, and newborn characteristics (birthweight, APGAR, gestational age) were statistically significant but of little importance in explaining the outcomes. Both examining regression coefficients and systematically omitting variables showed social factors (often emphasized by epidemiologists) to have markedly greater effects than the combination of health measures (often stressed by economists) in predicting achievement. However, mental health in childhood is identified as among the important predictors. Record linkage across population datasets from health, education, and family services ministries allowed: tracking health and educational attainment at different times in a child's life, following a large number of cases across childhood, considerable sensitivity testing, controlling for unmeasured family and neighborhood effects, generating an extensive list of predictors, estimating effect sizes, and comparing Manitoba results with those of well-known American studies.
Guideline concordance is one of the metrics used by the Cancer Quality Council of Ontario and Cancer Care Ontario to assess the quality of cancer care and to drive quality improvement.
The rates for ...lung cancer surgical resection and concordance with the Cancer Care Ontario postoperative adjuvant chemotherapy (AC) guideline were assessed by health region during two time periods (2010-2011 and 2012-2013) according to five equity measures (age, sex, neighborhood income, location of residence and size of immigrant population).
Of the patients with stage I/II NSCLC, 52.2% to 63.0% underwent surgical resection in the province of Ontario, Canada; for patients with stage IIIA disease, the rate was 26.4%. The probability of a surgical resection decreased substantially with age; only 26.9% of those with potentially resectable (stage I-IIIA) disease over 80 years underwent surgery. The use of postoperative AC increased modestly over the time of the study but the rate of use varied widely by health region (34.6 to 84.6%). Patients in rural areas were as likely to receive AC as urban dwellers; however, older aged patients (≥65 years) and those from the lowest income neighborhoods were significantly less likely to receive AC.
Surgical rates and the use of AC vary by health region in Ontario and by age and level of neighborhood income despite universal access in a publicly funded health care system. The reasons for this variance are unclear but warrant further study.
Presented in part at the 15th World Conference on Lung Cancer, Sydney, Australia, 27-30 October 2013
This study considers the problem of testing the difference between treatment and control groups on m ≥ 2 measures when it is assumed a priori that the treatment group will perform better than the ...control group on all measures. Two procedures are investigated that do not rest on the assumptions of covariance homogeneity or multivariate normality: a likelihood ratio test based on a bootstrap critical value and a composite step-down procedure based on trimmed means. Type I error rates of both procedures are insensitive to assumption violations. Procedures that test a directional alternative hypothesis can be substantially more powerful than a procedure that tests a nondirectional hypothesis for certain configurations of the population mean vectors. The differences in average power of the investigated procedures are a function of the configuration of the population means, the magnitude of correlation among the outcome measures, and the shape of the population distribution.
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