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Biomedical subjects

Janet E Hux

Publications and source records attributed to Janet E Hux.

12 recordsLinked to original sources
PubMed2003

Educating physicians to reduce benzodiazepine use by elderly patients: a randomized controlled trial.

BACKGROUND: Benzodiazepine use by elderly patients is associated with adverse outcomes including increased risk of falls and fractures, motor vehicle accidents and cognitive impairment. Recent studies suggest that individualized feedback and education to physicians may improve drug prescribing. In this study, we evaluated an intervention to address the inappropriate prescribing of benzodiazepines for elderly patients. METHODS: We identified 1624 primary care physicians who wrote at least 10 prescriptions for the target drugs in a 2-month period and randomly assigned these physicians to the intervention group or the control group. We obtained data from the Ontario Drug Benefit claims database, which covers all Ontario residents aged 65 years and over for drugs selected from a minimally restrictive formulary. Every 2 months for 6 months, confidential profiles of benzodiazepine prescription use coupled with evidence-based educational bulletins were mailed to the intervention group. The control group received feedback and educational bulletins about first-line antihypertension drug prescribing for elderly patients. Our main outcome measures were reductions in the proportion of each physician's total benzodiazepine prescriptions for long-acting agents, combinations of benzodiazepines with other psychoactive medications (including other benzodiazepines) and long-term benzodiazepine therapy. RESULTS: After randomization, 168 physicians agreed to be in the intervention group and 206 in the control group. Their demographic and prescribing characteristics were similar. Although the proportion of long-acting benzodiazepine prescriptions decreased by 0.7% in the intervention group between the baseline period and the end of the intervention period (from 20.3%, or a mean of 29.5 prescriptions, to 19.6%, or a mean of 27.7 prescriptions) and increased by 1.1% in the control group (from 19.8%, or a mean of 26.4 prescriptions, to 20.9%, or a mean of 27.7 prescriptions) (p = 0.036), this difference was not clinically significant. There was no significant difference over the study period in either combination prescribing of benzodiazepines or in prescriptions for long-term benzodiazepine therapy. INTERPRETATION: We did not find that a program of confidential feedback and educational material offered to Ontario primary care physicians had a clinically significant impact on their benzodiazepine prescribing.

Adult↗
PubMed2003

Relationship between avoidable hospitalizations for diabetes mellitus and income level.

BACKGROUND: Acute diabetic emergencies are potentially avoidable or amenable to timely and effective outpatient therapy. OBJECTIVE: To evaluate the relationship between socioeconomic status (SES) and acute complications of diabetes mellitus in Ontario. METHODS: We used a population-based cohort of persons with diabetes mellitus (N = 605 825) derived from hospital and physician service claims between April 1, 1992, and March 31, 1999. Socioeconomic status was estimated using neighborhood-level data from the 1996 Canadian Census. Outcome events were defined as 1 or more hospitalizations or emergency department visits for hyperglycemia or hypoglycemia. RESULTS: There was a clear inverse gradient between income level and event rates. Individuals in the lowest income quintile were 44% more likely to have an event than those in the highest quintile (16.4% vs 11.4%; P<.001) and had a greater propensity toward recurrent emergency department admissions (1.9 vs 1.6 episodes per patient; P<.001). The gradient was most marked in 45- to 64-year-olds (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.69-1.82) and less apparent in children (OR, 1.06; 95% CI, 0.99-1.13). The relationship between SES and events persisted after adjusting for age, sex, urban vs rural residence, comorbidity, frequency of physician visits, continuity of care, physician specialty, and geographic region (adjusted OR, 1.09 [95% CI, 1.08-1.10] per quintile level). In contrast, admission rates for non-ambulatory care-sensitive conditions (appendicitis and hip fracture) were unaffected by SES. CONCLUSION: Even when some economic barriers to accessing care are removed, patients from low-SES neighborhoods still experience an excess number of hospitalizations for conditions that should be prevented by optimal care in the ambulatory setting.

Acute Disease↗
PubMed2003

Hemodialysis infection prevention with polysporin ointment.

Hemodialysis patients in whom permanent vascular access cannot be achieved are dependent on a central venous catheter. In such patients, catheter-related infections are a common and serious complication. This study was a randomized clinical trial to determine if topical Polysporin Triple antibiotic ointment applied to the central venous catheter insertion site could reduce the incidence of catheter-related infections. A total of 169 patients receiving hemodialysis through a central venous catheter were randomized to receive Polysporin Triple or placebo using a double-blind study design. In the 6-mo study period, infections were observed in more patients in the placebo group than in the Polysporin Triple group (34 versus 12%; relative risk, 0.35; 95% CI, 0.18 to 0.68; P = 0.0013). The number of infections per 1000 catheter days (4.10 versus 1.02; P < 0.0001) and the number of bacteremias per 1000 catheter days (2.48 versus 0.63; P = 0.0004) were also greater in the placebo group. Within the 6-mo study period, there were 13 deaths in the placebo group as compared with 3 deaths in the Polysporin Triple group (P = 0.0041). When all available follow-up information was included, the difference in survival remained significant (19 versus 9 deaths; P = 0.0027). Within the first 6 mo, infections were observed in 7 of the 13 placebo subjects who died (54%) as compared with no infections in the three Polysporin Triple subjects who died. The prophylactic application of topical Polysporin Triple antibiotic ointment to the central venous catheter insertion site reduced the rate of infections and was associated with improved survival in hemodialysis patients.

Administration, Topical↗
PubMed2003

Markers of access to and quality of primary care for aboriginal people in Ontario, Canada.

OBJECTIVES: We evaluated primary care accessibility and quality for Ontario's aboriginal population. METHODS: We compared a defined aboriginal cohort with nonaboriginal populations with analogous geographic isolation and low socioeconomic status. We determined rates of hospitalization for the following indicators of adequacy of primary care: ambulatory care-sensitive (ACS) conditions and utilization of referral care-sensitive (RCS) procedures from administrative databases. RESULTS: ACS hospitalization rates, relative to the general population, were 2.54, 1.50, and 1.14 for the aboriginal population, the geographic control populations, and the socioeconomic control populations, respectively. The relative RCS procedure utilization rates were 0.64, 0.91, and 1.00, respectively. CONCLUSIONS: The increased ACS hospitalization rate and reduced RCS procedure utilization rate suggest that northern Ontario's aboriginal residents have insufficient or ineffective primary care.

Acute Disease↗
PubMed2003

Quantifying the risk of infectious diseases for people with diabetes.

OBJECTIVE: In vitro evidence shows that immune function is compromised in people with diabetes. Although certain rare infections are more common and infection-related mortality is higher, the risk of acquiring an infectious disease for diabetic patients has never been quantified. RESEARCH DESIGN AND METHODS: A retrospective cohort study using administrative data compared all people with diabetes in Ontario, Canada, on 1 April 1999 to matched nondiabetic people (n = 513,749 in each group). The risk ratios of having an infectious disease and of death attributable to infectious disease between those with and without diabetes were calculated. Secondary analysis individually examined common infectious diseases. The study was repeated using a second pair of cohorts defined in 1996 to confirm stability of the estimates. RESULTS: Nearly half of all people with diabetes had at least one hospitalization or physician claim for an infectious disease in each cohort year. The risk ratio for diabetic versus nondiabetic people was 1.21 (99% CI 1.20-1.22) in both cohort years. The risk ratio for infectious disease-related hospitalization was up to 2.17 (99% CI 2.10-2.23). The risk ratio for death attributable to infection was up to 1.92 (1.79-2.05). Many individual infections were more common in people with diabetes, especially serious bacterial infections. CONCLUSIONS: Diabetes confers an increased risk of developing and dying from an infectious disease, corroborating both in vitro evidence and commonly held clinical belief. In addition to microvascular and macrovascular sequelae, clinicians should consider infection a complication of diabetes.

Aged↗
PubMed2003

Processes and outcomes of care for diabetic acute myocardial infarction patients in Ontario: do physicians undertreat?

OBJECTIVE: To compare the health service utilization and long-term outcomes of acute myocardial infarction (AMI) patients with and without diabetes in Ontario. RESEARCH DESIGN AND METHODS: We examined 25,697 patients from Ontario (6,052 and 19,645 patients with and without diabetes, respectively) who were hospitalized because of AMI between 1 April 1992 and 31 December 1993. Using linked administrative databases, we determined the use of invasive cardiac procedures at 1 year as well as the intensity of specialty follow-up care and use of evidence-based pharmacotherapies (among elderly individuals) within the first 90 days of hospital discharge. Outcomes examined included mortality and recurrent cardiac admissions at 30 days and 5 years post AMI. Multivariable analyses adjusted for sociodemographic and case-mix characteristics, attending physician specialty, and admitting hospital characteristics. RESULTS: Despite being at significantly higher risk for death at baseline, diabetic patients were less likely to be followed-up by a cardiologist (22.2 vs. 25.6%, P < 0.001), to receive myocardial revascularization (12.6 vs. 14.9%, P < 0.001), to receive beta-blockers (34.2 vs. 44.0%, P < 0.001), and to receive aspirin therapy (59.7 vs. 63.5%, P < 0.001) after AMI than their nondiabetic counterparts. Diabetes was an important independent predictor of 5-year morbidity (adjusted hazard ratio 1.52, 95% CI 1.45-1.59) and 5-year mortality outcomes (1.57, 1.50-1.63). Variations in processes of care were marginally associated with higher nonfatal complication rates for diabetic patients. CONCLUSIONS: When managing AMI patients with diabetes in Ontario, physician treatment aggressiveness does not correspond appropriately to the baseline risk of patients.

Aged↗
PubMed2002

The impact of diabetes on cardiovascular risk factors and outcomes in a native Canadian population.

We measured cardiovascular disease (CVD) risk factors and their relationship to glucose intolerance in a Native Canadian population with very high rates of Type 2 diabetes mellitus. Five hundred and twenty five study-eligible Ojibwa-Cree individuals age 18 and over in the community of Sandy Lake, Canada who had participated in a population-based survey were studied. Diabetes status, plasma concentrations of total cholesterol (TC), triglycerides (TG), high density lipoprotein cholesterol (HDL-C), calculated low density lipoprotein-cholesterol (LDL-C), waist/hip ratio (WHR), BMI, systolic and diastolic BP, and history of smoking were compared to a standard national population. Extremely high rates of obesity (BMI and WHR) were identified in the study population and were associated with increasing glucose intolerance for both males and females. Rates of smoking exceeded 70 and 80% in females and males, respectively. Interestingly, despite obesity individuals who had normal glucose tolerance had significantly lower rates of high risk TC, TG, LDL-C, and HDL-C levels compared to a national Canadian population survey. However, with worsening glucose intolerance, TC, TG, LDL-C and HDL-C dramatically deteriorated in comparison to nationally published levels. These changes in cardiovascular risk factors, as a consequence of diabetes, appear to result in increased clinical outcomes. Admission to hospital for Ischemic Heart Disease (IHD) for Sandy Lake residents increased from a rate of 34.8/10,000 to 109.1/10,000 in 15 years. Although this and similar populations have historically reported low rates of CVD, the impact of diabetes on lipid risk factor is having devastating consequences on cardiovascular outcomes. This trend is expected to continue unless the high rates of diabetes can be modified.

Adult↗
PubMed2002

Bayeswatch: an overview of Bayesian statistics.

Increasingly, clinical research is evaluated on the quality of its statistical analysis. Traditionally, statistical analyses in clinical research have been carried out from a 'frequentist' perspective. The presence of an alternative paradigm - the Bayesian paradigm - has been relatively unknown in clinical research until recently. There is currently a growing interest in the use of Bayesian statistics in health care research. This is due both to a growing realization of the limitations of frequentist methods and to the ability of Bayesian methods explicitly to incorporate prior expert knowledge and belief into the analyses. This is in contrast to frequentist methods, where prior experience and beliefs tend to be incorporated into the analyses in an ad hoc fashion. This paper outlines the frequentist and Bayesian paradigms. Acute myocardial infarction mortality data are then analysed from both a Bayesian and a frequentist perspective. In some analyses, the two methods are seen to produce comparable results; in others, they produce different results. It is noted that in this example, there are clinically relevant questions that are more easily addressed from a Bayesian perspective. Finally, areas in clinical research where Bayesian ideas are increasingly common are highlighted.

Bayes Theorem↗
PubMed2002

Reporting of numerical and statistical differences in abstracts: improving but not optimal.

OBJECTIVE: The reporting of relative risk reductions (RRRs) or absolute risk reductions (ARRs) to quantify binary outcomes in trials engenders differing perceptions of therapeutic efficacy, and the merits of P values versus confidence intervals (CIs) are also controversial. We describe the manner in which numerical and statistical difference in treatment outcomes is presented in published abstracts. DESIGN: A descriptive study of abstracts published in 1986 and 1996 in 8 general medical and specialty journals. INCLUSION CRITERIA: controlled, intervention trials with a binary primary or secondary outcome. Seven items were recorded: raw data (outcomes for each treatment arm), measure of relative difference (e.g., RRR), ARR, number needed to treat, P value, CI, and verbal statement of statistical significance. The prevalence of these items was compared between journals and across time. RESULTS: Of 5,293 abstracts, 300 met the inclusion criteria. In 1986, 60% of abstracts did not provide both the raw data and a corresponding P value or CI, while 28% failed to do so in 1Dr. Hux is a Career Scientist of the Ontario Ministry of Health and receives salary support from the Institute for Clinical Evaluative Sciences in Ontario.996 ( P <.001; RRR of 53%; ARR of 32%; CI for ARR 21% to 43%). The variability between journals was highly significant ( P <.001). In 1986, 100% of abstracts lacked a measure of absolute difference while 88% of 1996 abstracts did so ( P <.001). In 1986, 98% of abstracts lacked a CI while 65% of 1996 abstracts did so ( P <.001). CONCLUSIONS: The provision of quantitative outcome and statistical quantitative information has significantly increased between 1986 and 1996. However, further progress can be made to make abstracts more informative.

Abstracting and Indexing↗
PubMed2002

A brief note on overlapping confidence intervals.

Clinical researchers frequently assess the statistical significance of the difference between two means by examining whether the two 95% confidence intervals overlap. The purpose of this brief communication is to illustrate that the 95% confidence intervals for two means can overlap and yet the two means can be statistically significantly different from one another at the alpha = 0.05 level.

Confidence Intervals↗
PubMed2002

Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm.

OBJECTIVE: Accurate information about the magnitude and distribution of diabetes can inform policy and support health care evaluation. We linked physician service claims (PSCs) and hospital discharge abstracts (HDAs) to determine diabetes prevalence and incidence. RESEARCH DESIGN AND METHODS: A retrospective cohort was constructed using administrative data from the national HDA database, PSCs for Ontario (population 11 million), and registries carrying demographics and vital statistics. All HDAs and PSCs bearing a diagnosis of diabetes (ICD9-CM 250) were selected for 1991-1999. Two previously reported algorithms for identification of diabetes were applied as follows: "1-claim" (any HDA or PSC showing diabetes) and "2-claim" (one HDA or two PSCs within 2 years showing diabetes). Incident cases were defined as individuals who met the criteria for diabetes for the first time after at least 2 years of observation. For validation, diagnostic data abstracted from primary care charts (n=3,317) of 57 randomly selected physicians were linked to the administrative data cohort, and sensitivity and specificity were calculated. RESULTS: -In 1998, 696,938 individuals met the 1-claim criteria and 528,280 met the 2-claim criteria. Sensitivity for diabetes was 90 and 86%; for the 1- and 2-claim algorithms, specificity was 92 and 97%, respectively, and positive predictive values were 61 and 80%, respectively. Using the 2-claim algorithm, the all-age prevalence increased from 3.2% in 1993 to 4.5% in 1998 (6.1% in adults). Incidence remained stable. CONCLUSIONS: Administrative data can be used to establish population-based incidence and prevalence of diabetes. Diabetes prevalence is increasing in Ontario and is considerably higher than self-reported rates.

Algorithms↗